Evidence-based design

Although much attention in healthcare is paid to clinical issues and to the medical care patients receive, recently little attention has been paid also to the physical space where patient stay. Evidence-based design (EBD) is an approach to healthcare design that give importance to design features that impact patient health, well-being, mood, and safety, as well as staff stress and safety. The approach focused on the relations between the quality and the features of the hospital environment and the patient healing.

EBD is the process of basing decisions about the built environment on credible research to achieve the best possible outcomes (The Center for Health Design, 2008). “Evidence-based design is the conscientious, explicit and judicious use of current best evidence from research and practice in making critical decisions, together with an informed client, about the design of each individual and unique project.” (Hamilton, DK & DH Watkins 2009)

It is created by a growing body of research showing that a proper design of the built environment contributes to improve key outcomes both patient and staff oriented. Some of these are: encourage patient healing, increasing patient and staff safety, reducing patient and staff stress, improving patient and family satisfaction, increasing staff effectiveness, reducing staff turnover, and consequently reducing cost. 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 constructions, expansions 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 and therefore research that is specific to the project's objectives is almost always required. In the last analysis, though, 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 health-care field but has many relations with complementary fields and some fallouts in distant fields. This approach appeal to many who are directly and indirectly involved in this area of research involves. the positive effect is shown from the patients and families, which have higher-quality stays; physicians, who practice based on medical evidence and the 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:
 * social support (patients, family, staff);
 * control (privacy, choices, escape);
 * positive distractions (artwork, music, entertainment);
 * influence of nature (plants, flowers, water, wildlife, nature sounds).
 * Clinicians focus on medical and scientific literature, which includes:
 * treatment modalities (models of care, technology);
 * quality & safety (infections, errors, falls);
 * exercise (exertion, rehabilitation).
 * Administration refers to management literature:
 * financial performance (margin, cost per patient day, nursing hours);
 * operational efficiency (transfers, utilization, resource conservation);
 * satisfaction (patient, staff, physician, turnover).
 * Evidence-Based Metrics includes Research Tools and Methods for Practitioners:
 * Work Measurement PDA (Time Study RN/MD);
 * Design for Efficiency (Layout-iQ);
 * Patient and Resource Workflow (Rapid Modeling).

Approximately 1200 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.

Background
Hospitals 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 towareds 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 underline the importance of quietness, proper lighting, warmth, and clean water. 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 have been developed in the 1960s. For example, in the 1970s in the USA and in the UK architectural researchers have studied the impact of hospital layout on staff effectiveness (Clipson & Johnson 1987; Clipson & Wehrer 1973; Medical Architecture Research Unit, 1971-1977) and social scientists have studied issues such as guidance and wayfinding (Carpman & Grant 1993). Besides, architectural researchers have explored how Post-Occupancy Evaluation (POE) provide useful advices 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 use and appliance into each step of the design process; more than 600 credible studies with specific environmental design relevance have been identified.

Performance Based Building Design (PBBD)
From the perspective of the building industry, EBD is tightly related to Performance-Based Building Design practices. PBBD, as an approach to design process, attempts to create clear and statistical relationships between design decisions and requirements satisfaction levels evidenced by the building systems. Like EBD, PBBD uses research evidence to predict performance related to design decisions. however, the decision making process is not a linear one: for the build environment is a complex system. Choices cannot be based on simple cause-and-effect predictions; instead they depend on many variable components and on the mutual relations established one each other. For example, even technical systems such as heating, ventilation, and air-conditioning systems have many interrelated design choices. even related performance requirements, such as energy use, comfort, use cycles, and so on are variable components.

Evidence Based Medicine
Evidence Based Medicine (EBM) is defined as the systematic process of evaluating scientific research that is used as the basis for clinical treatment choices (Claridge & Fabian, 2005). Sackett, Rosenberg, Gray, Haynes, and Richardson (1996) 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.” (British Medical Journal). It is currently being used in the healthcare industry to help convince decision-makers to invest the time and money to build better buildings and realize strategic business advantages as a result. As medicine has increasingly moved toward EBM, healthcare design is increasingly going toward approaches that link hospitals’ physical environments to healthcare outcomes, such as EBD.

Current state
The idea that physical environment can impact patient wellness, staff efficiency, and financial performance has been increasing for about 30 years and has given source to many studies and researches aimed to infer from evidence practical recommendations for healthcare building design. As EBD becomes more widespread, supported by a growing body of evidence, many healthcare organizations are realzing its importance, are transposing its principles, and trying to build their facilities with the guidance of EBD practitioners. Even though no standards for it have existed until now, recently has been rolled out a certification and the accreditation program by The Center for Health Design. It has also developed Pebble Project, together with InformeDesign, a not-for-profit clearinghouse for design and human behaviour research. Pebble Project is a joint research effort between the CHD and selected healthcare providers and has the purpose to deepen how to build environments affect patients and staff, and disseminate results.

Research centers

 * The Center for Health Design & Robert Wood Johnson Foundation
 * Georgia Tech
 * InformeDesign
 * The Picker Institute

Accreditation and cerification
The Evidence Based Design Accreditation and Certification (EDAC) program has been rolled out in 2009 by The Center for Health Design with the purpose to provide nationally recognized accreditation and to promote the use of EBD processes in healthcare building projects. Therefore, its intent is to make EBD an accepted and credible approach to improve healthcare outcomes. The EDAC is meant to identify qualified experts experienced in EBD practice and to teach about the research process, such as identifying, hypothesizing, implementing, gathering and reporting credible data associated with a health care project.

Methodology and strategies
In the first instance EBD methodology could be divided in four subsequent steps: Other sources provide different and more specific proceedings to guide practical applications to achieve EBD objectives. Some of them are listed below.
 * reviewing existing research literature to select significant findings and recommendations;
 * matching referenced findings with data gathered from site visits, surveys results, subject matter experts;
 * prediciting the outcomes of design decisions;
 * tracking the positive outcomes for design implementation.

Meta-analysis template
In his book "Evidence-based Policy: A Realistic Perspective", Ray Pawson (2006) suggests a meta-analysis template that may be applicable for EBD. By using such a protocol the field will be able to provide designers with a credible source for evidence-based design. Systematic review process should follow six essential steps:
 * 1. Formulating the review question
 * 2. Identifying and collecting evidence
 * 3. Appraising the quality of the evidence
 * 4. Extracting and processing the data
 * 5. Systematizing the data
 * 6. Disseminating the findings

Conceptual model for the application of EBD
According to Hamilton ("Four Levels of Evidence-Based Practice", The AIA Journal of Architecture, 2006), environmental research is more likely to result in performance guidelines than in prescriptive regulation. Different information sources are potentially helpful: literature from psychology, sociology, anthropology, economics, management, engineering, and industrial design. Internet, press, conferences, and exemplary facilities are also good resources. To show evidence-based different types of practice, the model below illustrates four ways of dealing with research. this includes identifiying four increasingly levels and the related methods.
 * Level 1
 * analysing the literature in the field in order to follow the related environmental researches
 * reading the meaning of the evidence in the relationships to the project
 * Level 2
 * foreshadowing the expected outcomes of design decisions upon the general readings
 * measuring the results through the analysis of the implications, the construction of a chain of logic connection from decision and future outcome, in order to reduce arbitrary decisions
 * Level 3
 * reporting the results publicly, writing or speaking about results, and moving in this way information beyond design team
 * subjecting methods and results to others who may or may not agree with the findings
 * Level 4
 * publishing the findings in reviewed journals
 * collaborating with academic or social scientists

Working model for the application of EBD
The ”White Paper (series 3/5)” written by The Center for Health Design presents a working model that help designers to use and implement EBD decision-making practices. As shown in figure, at the center of the model is the main goal that is providing a healing environment; positive outcomes achievement depends on three investments: All three investments depend on existing research, and the investment results should contribute to the growing body of EBD approach.
 * designed infrastructure including the built environment and technology,
 * reengineered clinical and administrative practices to maximize infrastructure investments
 * transformational leadership to maximize the human capital and infrastructure investments

Ten strategies for the implementation of EBD
The ”White Paper (series 3/5)” written by The Center for Health Design identifies ten strategies to help decision making, according to EBD practices. They are specified below.
 * 1. 	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.
 * 2. 	Use an integrated multidisciplinary approach with consistent senior involvement, ensuring that everyone with problem-solving tools is included. It is essential stimulate synergy between different community to maximize efforts, outcomes and interchanges.
 * 3. 	Maintain a patient-and-family-centered approach: patient and family experience are key to define aims and to assess outcomes efficacy.
 * 4.	Focus on financial operating impacts, getting past the paralysis of first-cost, exploring the cost-effectiveness of design options over time and considering multiyear returns of investment.
 * 5. 	Apply disciplined participation and criteria management. These processes uses decision-making tools such as SWOT analysis, analytic hierarchy processes, and decision trees that can also be used in design processes, particularly for critical technical aspects, such as structural, fire safety, or energy design.
 * 6. 	Establish quantitative criteria linked to incentives in order to increase motivation of the team design through the definition of measurable outcomes and to involve end users through checklists, surveys, simulations.
 * 7. 	Use strategic partnerships to accelerate innovation, in order to create innovative new products using hospital staff expertise and leverage.
 * 8. 	Support and demand simulation and testing assuming the patient’s perspective through making lighting, energy, and other kinds of models; and computer visualizations.
 * 9. 	Use a lifecycle perspective (30–50 years), from the strategic planning to the sustainment, especially to explore the lifecycle return on investment of design strategies as they impact safety and work-force outcomes.
 * 10. 	Overcommunicate: positive outcomes are closely linked to the involvement of clinical staff and community members; it can be reached by attending meetings, sending out newsletters, creating Web cams, and other tools.

Tools
Traditionally, evidence-based design has been applied for the measuring of the efficacy of a building design; it is usually carried out at the post-construction stage as a part of a Post-Occupancy Evaluation (POE). POE evidences the effectiveness or the weaknesses of design decisions in relation to human behaviour in built environment. Usually questions concern issues such as acoustics, odor control, vibration, lighting, ser-friendliness, and so on, and are binary-choice (acceptable or not acceptable). Other research techniques, such as direct observation, photography, checklists, interviews, direct surveys, focus groups are utilized to supplement traditional design research methods. Several assessment tools are developed by The Center for Health Designand by *The Picker Institute, to help healthcare managers and designers in gathering information on consumer's needs, assessing their satisfaction, measuring quality improvements. These tools are commonly used in EBD practices and can be downloaded by the CHD web site.
 * Patient Environmental Checklist is addressed to patient and is useful to assess an existing facility's strong and weak points. Specific environment features are evaluated by patients and their families through a 5-point scale. Checklist quickly shows which areas need to be improved.
 * Patient Survey’s purpose is to achieve information on patients' experiences with the built environment. Questions range is wide, since patients' priorities may be very different from those of administrators or designers.
 * Focus Groups with consumers are oriented to learn more about their specific needs and generate ideas for future solutions.

Recommendation for EBD
The following are three macro-objectives related to the EBD approach and some related specific objectives analyzed in ”White Paper (series 3/5)” written by The Center for Health Design; for each are briefly explained some practical actions to achieve the goal.


 * OBJECTIVE 1: IMPROVING PATIENT SAFETY THROUGH ENVIRONMENTAL MEASURES
 * 1.1	Reducing Hospital-Acquired Infections. Infection rates are lower when there is good air and water quality and physical separation. This correspond to the use of air quality control measures, to the choice of easy-to-clean floor, wall, and furniture coverings, and to the preference for single-bed rooms with private toilets to enable separation or isolation of patients.
 * 1.2	Reducing Medical Errors. Several studies show that medical errors are not caused only by the mistakes of a few individuals, but often they are linked to environmental factors. For example, error rates increase when there is an interruption or distraction from an unexpected noise (a telephone call), and they decrease significantly when the lighting level for work surfaces is sufficiently high.


 * OBJECTIVE 2: IMPROVING PATIENT OUTCOMES THROUGH ENVIRONMENTAL MEASURES
 * 2.1	Reducing Pain. Scientific studies have shown that exposing patients to nature can produce significant alleviation of pain. Besides, other researches also suggest that patients experience less pain when exposed to high levels of daylight in their rooms. Finally, some research also supports displaying visual art with nature subject matter helps reducing pain.
 * 2.2	Improving Patients’ Sleep. Sleep disruption and deprivation are common problems in healthcare buildings; increasing acoustic performance with reduced reverberation time increased sleep quality.
 * 2.3	Reducing Patient Stress. Patient stress is a significant negative outcome in which bears many other healthcare negative consequences. A physical environment that contains stressful features makes psychological patient state worse. Several experimental studies have shown that real or simulated views of nature can produce restoration from psychological stress in few minutes. Other studies based on behavioural observation suggest that gardens in hospitals can reduce stress among patients and families. On the other hand, some studies suggest that many patients respond negatively to abstract art, causing stressful reactions. Besides, many researches has shown that noise is an important stressor.
 * 2.4	Reducing Depression. Many studies show that exposure to bright artificial light and daylight is effective in improving mood and reducing depression, even for people affected by deep depression.
 * 2.5 Reducing Spatial Disorientation. Wayfinding problems in hospitals have a significant impact both on patients and visitors, who can be stressed and disoriented. A large body of literature has explored how people find their way through hospitals and other complex buildings (i.e. Space Syntax Analysis). For example, complex layouts are difficult to find one’s way in, and some studies have found that right turns are easiest to maintain.
 * 2.6 Improving Patient Privacy and Confidentiality. It is based on great evidence that the provision of single-bed rooms increases patient privacy. Furthermore, providing private discussion rooms near waiting, admission, and reception areas may help avoiding breaches of speech privacy.
 * 2.7 Fostering Social Support. Some studies recommend the provision of stays and waiting rooms with comfortable furniture arranged in small cluster, in order to encourage social interactions. Carpets instead of vinyl for floors in patient rooms seem to increase the length of people’s stay.


 * OBJECTIVE 3. IMPROVING STAFF OUTCOMES THROUGH ENVIRONMENTAL MEASURES
 * 3.1 Decreasing Staff Stress. Stress is the most common cause of staff retirement. Environmental stressors include noise, light, and multied-bed patient rooms. In fact, survey research shows that single-bed patient rooms are perceived to be less stressful for both family and staff than ones containting multi-beds.
 * 3.2 Increasing Staff Effectiveness. While most research IS aimed at patients, there is a growing body of evidence suggesting to improve hospital efficiency through making the jobs of staff easier. This can be achieved by spatial solution, environmental factors, technological devices.

Financial impact
Hospitals’ chiefs and designers say that building a patient-oriented facility increases marginally the cost of construction, and the extra expense does not pass along to patients. EBD practices, if applied to the whole healthcare system, maximize the capital investment by quantifiably improvements, producing a significant multiyear return on investment. In fact, cost savings resulting from reducing infections, decreasing staff turnover efforts, reducing hospitalization time, properly managed and monitored, match to financial benefits that continue for several years, making the innovations a long-term investment.