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Evidence-based design (EBD) is the process of constructing a building or physical environment based on scientific research to achieve the best possible outcomes. Evidence-based design is especially important in
evidence-based medicine Evidence-based medicine (EBM) is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients". The aim of EBM is to integrate the experience of the clinician, the values of t ...
, where research has shown that environment design can affect patient outcomes. It is also used in
architecture Architecture is the art and technique of designing and building, as distinguished from the skills associated with construction. It is both the process and the product of sketching, conceiving, planning, designing, and constructing buildings ...
,
interior design Interior design is the art and science of enhancing the interior of a building to achieve a healthier and more aesthetically pleasing environment for the people using the space. An interior designer is someone who plans, researches, coordin ...
,
landscape architecture Landscape architecture is the design of outdoor areas, landmarks, and structures to achieve environmental, social-behavioural, or aesthetic outcomes. It involves the systematic design and general engineering of various structures for constructio ...
,
facilities management Facility management or facilities management (FM) is a professional management discipline focused on the efficient and effective delivery of logistics and other support services related to real property and buildings. It encompasses multiple d ...
,
education Education is a purposeful activity directed at achieving certain aims, such as transmitting knowledge or fostering skills and character traits. These aims may include the development of understanding, rationality, kindness, and honesty ...
, and
urban planning Urban planning, also known as town planning, city planning, regional planning, or rural planning, is a technical and political process that is focused on the development and design of land use and the built environment, including air, water, ...
. Evidence-based design is part of the larger movement towards
evidence-based practices Evidence-based practice (EBP) is the idea that occupational practices ought to be based on scientific evidence. While seemingly obviously desirable, the proposal has been controversial, with some arguing that results may not specialize to indiv ...
.


Background

Evidence-based design (EBD) was popularized by the seminal study by Ulrich (1984) that showed the impact of a window view on patient recovery. Studies have since examined the relationships between design of the physical environment of hospitals with outcomes in health, the results of which show how the physical environment can lower the incidence of nosocomial infections, medical errors, patient falls, and staff injuries; and reduce stress of facility users, improve safety and productivity, reduce resource waste, and enhance sustainability. ''Evidence'' in EBD may include a wide range of sources of knowledge, from systematic literature reviews to practice guidelines and expert opinions. Evidence-based design was first defined as "the deliberate attempt to base design decisions on the best available research evidence" and that "an evidence-based designer, together with an informed client, makes decisions based on the best available information from research and project evaluations". The Center for Heath Design (CHD), a non-profit organization that supports healthcare and design professionals to improve the understanding and application of design that influence the performance of healthcare, patient satisfaction, staff productivity and safety, base their model on the importance of working in partnership with the client and interdisciplinary team to foster understanding of the client, preferences and resources. The roots of evidence-based design could go back to 1860 when
Florence Nightingale Florence Nightingale (; 12 May 1820 – 13 August 1910) was an English social reformer, statistician and the founder of modern nursing. Nightingale came to prominence while serving as a manager and trainer of nurses during the Crimean War ...
identified fresh air as "the very first canon of nursing," and emphasized the importance of quiet, proper lighting, warmth and clean water. Nightingale applied statistics to nursing, notably with "Diagram of the causes of mortality in the army in the East". This statistical study led to advances in sanitation, although the germ theory of disease was not yet fully accepted. The evidence-based design movement began much later in the 1970s with Archie Cochranes's book ''Effectiveness and Efficiency: Random Reflections on Health Services''. to collect, codify, and disseminate "evidence" gathered in randomised controlled trials relative to the built environment. A 1984 study by Roger Ulrich found that surgical patients with a view of nature suffered fewer complications, used less pain medication and were discharged sooner than those who looked out on a brick wall; and laid the foundation for what has now become a discipline known as evidence-based design. Studies exist about the psychological effects of lighting, carpeting and noise on critical-care patients, and evidence links physical environment with improvement of patients and staff safety, wellness and satisfaction. Architectural researchers have studied the impact of hospital layout on staff effectiveness, and social scientists studied guidance and
wayfinding Wayfinding (or way-finding) encompasses all of the ways in which people (and animals) orient themselves in physical space and navigate from place to place. Wayfinding software is a self-service computer program that helps users to find a location, ...
. Architectural researchers have conducted
post-occupancy evaluation Post Occupancy Evaluation (POE) has its origins in Scotland and the United States and has been used in one form or another since the 1960s. Preiser and colleagues define POE as "the process of evaluating buildings in a systematic and rigorous manner ...
s (POE) to provide advice on improving building design and quality. While the EBD process is particularly suited to healthcare, it may be also used in other fields for positive health outcomes and provision of
healing environments Healing environment, for healthcare buildings describes a physical setting and organizational culture that supports patients and families through the stresses imposed by illness, hospitalization, medical visits, the process of healing, and some ...
.


Evidence-based design for healthcare facilities

There is a growing awareness among healthcare professionals and medical planners for the need to create patient-centered environments that can help patients and family cope with the stress that accompanies illness. There is also growing supporting research and evidence through various studies that have shown both the influence of well-designed environments on positive patient health outcomes, and poor design on negative effects including longer hospital stays. Using biophilic design concepts in interior environments is increasingly argued to have positive impacts on health and well-being through improving direct and indirect experiences of
nature Nature, in the broadest sense, is the physical world or universe. "Nature" can refer to the phenomena of the physical world, and also to life in general. The study of nature is a large, if not the only, part of science. Although humans are ...
. Numerous studies have demonstrated improved patient health outcomes through environmental measures; exposing patients to nature has been shown to produce substantial alleviation of pain, and limited research also suggests that patients experience less pain when exposed to higher levels of daylight in their hospital rooms. Patients have an increased need for sleep during illness, but suffer from poor sleep when hospitalised. Approaches such as single-bed rooms and reduced noise have been shown to improve patient sleep. Natural daylight in patient rooms help to maintain
circadian rhythms A circadian rhythm (), or circadian cycle, is a natural, internal process that regulates the sleep–wake cycle and repeats roughly every 24 hours. It can refer to any process that originates within an organism (i.e., endogenous) and responds to ...
and improve sleep. According to Heerwagen, an environmental psychologist, medical models of health integrate behavioral, social, psychological, and mental processes. Contact with nature and daylight has been found to enhance emotional functioning; drawing on research from studies (EBD) on well-being outcomes and building features. Positive feelings such as calmness increase, while anxiety, anger, or other negative emotions diminish with views of nature. In contrast there is also convincing evidence that stress could be worsened and ineffective in fostering restoration in built environments that lack nature. Few studies have shown the restorative effects of gardens for stressed patients, families and staff. Behavioural observation and interview methods in post occupancy studies of hospital gardens have shown a faster recovery from stress by nearly all garden users. Limited evidence suggest increased benefits when these gardens contain foliage, flowers, water, pleasant nature sounds, such as birds and water.


Related approaches


Performance-based building design

EBD is closely related to
performance-based building design Performance-Based Building Design is an approach to the design of any complexity of building, from single-detached homes up to and including high-rise apartments and office buildings. A building constructed in this way is required to meet certain ...
(PBBD) practices. As an approach to design, PBBD tries to create clear statistical relationships between design decisions and satisfaction levels demonstrated by the building systems. Like EBD, PBBD uses research evidence to predict performance related to design decisions. The decision-making process is non-linear, since the building environment is a complex system. Choices cannot be based on cause-and-effect predictions; instead, they depend on variable components and mutual relationships. Technical systems, such as heating, ventilation and air-conditioning, have interrelated design choices and related performance requirements (such as energy use, comfort and use cycles) are variable components.


Evidence-based medicine

Evidence-based medicine Evidence-based medicine (EBM) is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients". The aim of EBM is to integrate the experience of the clinician, the values of t ...
(EBM) is a systematic process of evaluating scientific research which is used as the basis for clinical treatment choices. Sackett, Rosenberg, Gray, Haynes and Richardson argue that "evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients". It is used in the healthcare industry to convince decision-makers to invest the time and money to build better buildings, realizing strategic business advantages as a result. As medicine has become increasingly evidence-based, healthcare design uses EBD to link hospitals' physical environments with healthcare outcomes.


Research-informed design

Research-informed design (RID) is a less-developed concept that is commonly misunderstood and used synonymously with EBD, although they are different. It can be defined as the process of applying credible research in integration with the project team to inform the environmental design to achieve the project goals. Credible research here, includes qualitative, quantitative, and mixed methods approaches with the highest standards of rigor suitable for their methodology. It is important to understand that the literature for "research-informed" practices comes from
education Education is a purposeful activity directed at achieving certain aims, such as transmitting knowledge or fostering skills and character traits. These aims may include the development of understanding, rationality, kindness, and honesty ...
and not from the healthcare disciplines. The process involves application of the outcomes from literature review and empirical investigation to inform design during the design phase, given the constraints; and to share the process and the lessons learnt just like in EDB.


Research and accreditation

As EBD is supported by research, many healthcare organizations are adopting its principles with the guidance of evidence-based designers. The Center for Health Design developed the Pebble Project, a joint research effort by CHD and selected healthcare providers on the effect of building environments on patients and staff. ''Health Environment Research & Design'' journal and the Health Care Advisory Board are additional sources of information and database on EBD. The Evidence Based Design Accreditation and Certification (EDAC) program was introduced in 2009 by The Center for Health Design to provide internationally recognized certification and promote the use of EBD in healthcare building projects, making EBD an accepted and credible approach to improving healthcare outcomes. EDAC identifies those experienced in EBD and teaches about the research process: identifying, hypothesizing, implementing, gathering and reporting data associated with a healthcare project.


Process

There are four components to evidence-based design: *Gather qualitative and quantitative intelligence * Map strategic, cultural and research goals *Hypothesize outcomes, innovate, and implement translational design * Measure and share outcomes


Meta-analysis template for literature review

In his book ''Evidence-based Policy: A Realistic Perspective'', Ray Pawson suggests a meta-analysis template which may be applied to EBD. With this protocol, the field will be able to provide designers with a source for evidence-based design. A systematic review process should follow five steps: # Formulating the review question # Identifying and collecting evidence # Evaluating the quality of the evidence # Extracting, processing and systematizing data # Disseminating findings


Conceptual model

According to Hamilton, architects have a responsibility in translation of research in the field, and its application in informing designs. He further illustrates a conceptual model architects could use, that identifies four levels of addressing research and methods base on varying levels of commitment: * Level 1 ** Informed design decisions based on available literature on environmental research, based on applicability, such as the use of a state of the art technology or strategy based on the physical setting of the project * Level 2 ** Design decisions based on predictive performance and measurable outcomes, rather than subjective decisions based on random choice * Level 3 ** Results reported publicly, with the objective of moving information on the methods and results moving information beyond the design team, ** The peer review, makes the process more robust, as it could include varying perspectives from those who may or may not agree with the findings * Level 4 ** Publishing findings in peer-reviewed journals ** Collaborating with academic and social scientists


Working model

A white paper (series 3/5) from the Center for Health Design presents a working model to help designers implement EBD decision-making. The primary goal is providing a healing environment; positive outcomes depend on three investments: * Designed infrastructure, including the built environment and technology * Re-engineered clinical and administrative practices to maximize infrastructure investment * Leadership to maximize human and infrastructure investments All three investments depend on existing research.


Strategies

A white paper from the Center for Health Design identifies ten strategies to aid EBD decision-making: #Start with problems. Identify the problems the project is trying to solve and for which the facility design plays an important role (for example, adding or upgrading technology, expanding services to meet growing market demand, replacing aging infrastructure) #Use an integrated multidisciplinary approach with consistent senior involvement, ensuring that everyone with problem-solving tools is included. It is essential to stimulate synergy between different community to maximize efforts, outcomes and interchanges. #Maintain a patient- and family-centered approach; patient and family experiences are key to defining aims and assessing outcomes. #Focus on financial operations past the first-cost impact, exploring the cost-effectiveness of design options over time and considering multi-year investment returns. #Apply disciplined participation and criteria management. These processes use decision-making tools such as
SWOT analysis SWOT analysis (or SWOT matrix) is a strategic planning and strategic management technique used to help a person or organization identify Strengths, Weaknesses, Opportunities, and Threats related to business competition or project planning. It ...
, analytic hierarchy processes and
decision tree A decision tree is a decision support tool that uses a tree-like model of decisions and their possible consequences, including chance event outcomes, resource costs, and utility. It is one way to display an algorithm that only contains con ...
s which may also be used in design (particularly of technical aspects such as structure, fire safety or energy use). #Establish incentive-linked criteria to increase design-team motivation and involve end users with checklists, surveys and simulations. #Use strategic partnerships to create new products with hospital-staff expertise and influence. #Encourage simulation and testing, assuming the patient's perspective when making lighting and energy models and computer visualizations. #Use a lifecycle perspective (30–50 years) from planning to product, exploring the lifecycle return on investment of design strategies for safety and workforce outcomes. #Overcommunicate. Positive outcomes are connected with the involvement of clinical staff and community members with meetings, newsletters, webcams and other tools.


Tools

Evidence-based design has been applied to efficacy measurements of a building's design, and is usually done at the post-construction stage as a part of a post-occupancy evaluation (POE). The POE assesses strengths and weaknesses of design decisions in relation to human behaviour in a built environment. Issues include acoustics, odor control, vibration, lighting and user-friendliness, and are binary-choice (acceptable or unacceptable). Other research techniques, such as observation, photography, checklists, interviews, surveys and focus groups, supplement traditional design-research methods. Assessment tools have been developed by The Center for Health Design and the Picker Institute to help healthcare managers and designers gather information on consumer needs, assess their satisfaction and measure quality improvements: * The ''Patient Environmental Checklist'' assesses an existing facility's strong and weak points. Specific environmental features are evaluated by patients and their families on a 5-point scale, and the checklist quickly identifies areas needing improvement. * The ''Patient Survey'' gathers information on patients' experiences with the built environment. The questions range is wide, since patients' priorities may differ significantly from those of administrators or designers. * ''Focus Groups'' with consumers learn about specific needs and generate ideas for future solutions.


References

* Cama, R., "Patient room advances and controversies: Are you in the evidence-based healthcare design game?", ''Healthcare Design'', March 2009. * Hall, C.R., "CHD rolls out evidence-based design accreditation and certification", ''Health Facilities Management'', July 2009. * Kirk, Hamilton D., "Research Informed Design & Outcomes for Healthcare" in ''Evidence Based Hospital Design Forum'', Washington, January 2009. * Stankos, M. and Scharz, B., "Evidence-Based Design in Healthcare: A Theoretical Dilemma", ''IDRP Interdisciplinary Design and Research e-Journal'', Volume I, Issue I (Design and Health), January 2007. * Ulrich, R.S.
"Effects of Healthcare Environmental Design on Medical Outcomes"
in ''Design & Health – The therapeutic benefits of design, proceedings of the 2nd Annual International Congress on Design and Health''. Karolinska Institute, Stockholm, June 2000. * Webster, L. and Steinke, C., "Evidence-based design: A new direction for health care". ''Design Quarterly'', Winter 2009 * Sadler, B.L., Dubose, J.R., Malone, E.B. and Zimring, C.M., "The business case for building better hospitals through evidence based design". White Paper Series 1/5,

', Center for Health Design, September 2008. * Ulrich, R.S., Zimring, C.M., Zhu, X., Dubose, J., Seo, H.B., Choi, Y.S., Quan, X. and Joseph, A., "A review of the research literature on evidence based healthcare design", White Paper Series 5/5,

', Center for Health Design, September 2008.


Further reading

* ''A Visual Reference to Evidence-Based Design'' by Jain Malkin. * ''Study Guide 1: An Introduction to Evidence-Based Design: Exploring Healthcare and Design''. * ''Study Guide 2: Building the Evidence-Base: Understanding Research in Helathcare Design''. *
Study Guide 3: Integrating Evidence-Based Design: Practicing the Healthcare Design Process
'. *
A Practitioner's Guide to Evidence-Based Design
' by Debra D. Harris, PhD, Anjali Joseph, PhD, Franklin Becker, PhD, Kirk Hamilton, FAIA, FACHA, Mardelle McCuskey Shepley, AIA, D.Arch. * ''Evidence-Based Design for Multiple Building Types'' by D. Kirk Hamilton and David H. Watkins. * Stout, Chris E. and Hayes, Randy A. ''The evidence-based practice: methods, models, and tools for mental health professionals''. John Wiley and Sons, January 2005. * Ulrich, R., Quan, X., Zimring, C., Joseph, A. and, Choudhary, R., "The Role of the Physical Environment in the Hospital of the 21st Century". Report to the Center for Health Design, September 2004. * Cama, R., (2009). ''Evidence-Based Healthcare Design''. Hoboken, New Jersey: John Wiley & Sons, Inc. * Phiri, M. (2015). ''Design Tools for Evidence-Based Healthcare Design''. Abingdon & New York: Routledge. * Phiri, M. & Chen, B. (2014). ''Sustainability and Evidence-Based Design in Healthcare Estate''. Heidelberg: Springer.


External links


The Center for Health Design

Role of the Physical Environment in the Hospital of the 21st Century
Report published by The Center for Health Design in 2004 summarizing evidence-based design research for healthcare
InformeDesign
Research database of studies linking environment to outcomes
Center for Health Systems and Design

Picker Institute

Tulane Center for Evidence-Based Global Health
{{DEFAULTSORT:Evidence-Based Design Health care quality Decision-making Health informatics Evidence-based practices