Design and Health World Health Design

Dialogue: Cultural Challenges

John Cooper, consultant
Phil Nedin and John Cooper go head to head on the role that research and evidence-based design can play in improving the quality and performance of the global health estate.

Used by architects, interior designers, engineers, and estates and facilities managers in the planning, design and construction of healthcare buildings, evidence based design (EBD) is one of the more popular tools available within a rich and complex tapestry of research methodologies.

Project teams, working with informed clients, applying an EBD methodology, create a design solution following an assessment of the best available information from the research literature, post project evaluations and from evidence collated from the client’s own operations.

A successful EBD solution, tested and measured regularly, should then demonstrate improvements in clinical outcomes, economic performance and patient, staff and visitor satisfaction.

The founding principles of EBD are in the main without dispute. Where controversy reigns appears to be where the methodology has been cannibalised or misused for commercial gain in order to convince decision-makers to rightly or wrongly commit to a capital investment.

Phil Nedin, global head of healthcare, ARUP
Fad or fashion

Speaking in a live debate, hosted by the International Academy for Design & Health at the UK’s annual Healthcare Estates conference earlier his month, Anshen + Allen director, John Cooper and Arup’s global head of healthcare, Phil Nedin both recognised EBD as an international issue, but one which should be considered within local cultural contexts.

Tackling attacks on EBD as a ‘design’ fad or a fashion, Cooper said: “Is EBD yesterday’s buzz-word? Has it been displaced by ‘lean thinking’? Is EBD a thing of the past? Let’s not simply throw the evidence out because it’s been misused.” He recalled design briefs in the late 90s that demanded new healthcare facilities to possess 21st century qualities, querying: “Isn’t it amazing that here we are in 2008, and we’re still calling for 21st century hospitals?”

Cooper’s suggestion is that the UK has missed a trick and an opportunity to build an evidence base that will support and inform future design solutions, questioning whether anything has been learned about the impact of design on nosocomial infection, reducing patient falls or increasing staff retention. He says: “In the UK, between £17-23 billion has been spent on the healthcare estate in the last ten years, but precious little has been learned.”

Comparable methodologies
EBD first came to the fore in the US as the design equivalent to evidence-based medicine, which Nedin points out is at the heart of healthcare provision. “No therapy, drug or procedure is offered unless the necessary research and repeatable clinical trials have been successfully conducted.”

Recognising, however, the complexity of making a fair comparison of the value of applying similar scientific methodologies to clinical and non-clinical subjects, Nedin, whilst supporting the principle of research, identifies some important caveats. “Take the idea of the therapeutic environment, which architects, designers and psychologists are endorsing. It is largely intuitive that good acoustics, environmental control, natural ventilation, lighting, colour and art can bring patient benefits, but there are also increasing numbers of studies to support its case too.

“However, patients are spending less and less time in hospital environments – an average of 3.5 days rather than 11 days in the 1970s. Diagnostics is more regularly performed as an outpatient activity rather than as an elective procedure. The payback on the therapeutic environment is now longer per individual patient,” explains Nedin.

Delegates listening intent to the debate on evidence-based design
Complex relationships

The second caveat, he suggests, is concerned with the credibility of the evidence, and the ability to repeat a research study, given the complexity of the relationship between clinical outcomes and environmental space.

In the modern world of medicine, where the patient rather than the disease is increasingly the focus of care, Nedin says: “On what basis do we select patients for research? Each patient has their own unique clinical condition/s, and mental and physical characteristics, different levels of stress, and a specific drug regime.

“They will also hold different perceptions of the different models and levels of care they are subject to, and of the environmental space around them, not to forget different levels of social support from families and friends.”

Cooper suggests however that it is possible to measure the variables and develop an evidence-base, citing the work of the Centre for Health Design in the US, and particularly the Pebble Project, of which the new Pembury Hospital in Tonbridge Wells, UK, designed by Cooper, is a member. “There are over 600 studies in the US which will withstand peer review and demonstrate the impact of good design on clinical outcomes.

“It’s about taking a new building and making it a pre-requisite to measure the variables,” explains Cooper. By being a part of the Pebble Project, the Pembury Hospital is subject to an EBD approach that takes a small set of variables, such as nosocomial infection, the reduction of patient falls and the misapplication of drugs, and compares the outcomes in the new facility with those of the old facility.  “We can then see whether the evidence that supported the design solution has been rightly or wrongly applied,” says Cooper.

As a member of the Pebble fraternity, Cooper says he receives 30-40 e-mails every week saying, ‘Do you know anything about this?’, ‘What’s happening here?’ or ‘We’ve learnt this’. He says: “A member of the estates staff we worked with in the US spent six months working out which carpet offered the least resistance to pushing a trolley along. The work is invaluable because you can use it.

Cultural drivers
Cooper also recognises however that local cultural contexts must be taken into account when assessing the evidence. “If you go to Europe and talk about infection control, or if you go to the US, you’ll fi nd a lot of what we consider to be best practice is entirely cultural. It’s not absolute and that is a difficult issue when you’re building an evidence-base.”

In the US, he explains, “they use carpets in places we would never dream of, supported by a culture of steam cleaning once a week. We all operate within very different clinical as well as operational cultures internationally which adds another layer of complexity.”

Phil Nedin adds that examples such as the use of carpets versus vinyl flooring also demonstrate how different interpretations of the evidence may depend on the research objectives. “There is an assumption that the safest floor covering is a vinyl floor. But if you’re dry sweeping a vinyl floor or a visitor leaves the building dragging their coat behind them, all manner of dust and matter carrying a microbiological load can be stirred up.

“So suddenly, we’re beginning to think that carpets are pretty good because they act as a blotting paper – when the particles settle, they settle for good. But you must have a means of cleaning the carpet properly.”

Cooper adds, however, that research can also be used to challenge cultural paradigms. “There is apparently no evidence whatsoever to support the use of laminar flow curtains in orthopaedic theatres, and in the US they don’t use them.

“Any why are the British more combustible than any other nation? HTM81 is far more onerous than any other fire code in the US, Europe, Australia or any other area in which I’ve worked. This is an extraordinary restriction as we move towards 100% single rooms.

“Much of what we design is shaped entirely by the rigours of fire code. Research is needed to validate different hospital arrangements that do not increase the risk of mishap or injury due to fire.”

Danger of complacency
Despite his warnings about the use of evidence, Nedin says the danger is not getting proper research done that will help to develop the evidence-base. “Real problems emerge when something is intuitive and you try to write guidance around it without the research to support it.” 

Recalling a recent conference presentation he gave in the US, Nedin said: “I put up a slide of a map of the US divided into 30 different areas to demonstrate the changing climate from north to south, and east to west.

“In some of these regions, you can naturally ventilate for 80-90% of the year, in other areas you may not have considered appropriate, natural ventilation is possible for 50% of the time. In other areas, where the humidity is high, there may be ways of addressing that problem. Both the architects and the engineers said they would love to do that, but that the code ensured that the first decision was always to seal the hospital.”

Warning against complacency, Nedin said that when pressed on how the code had been developed to support sealing of the hospital, the designers said that when asked to attend the guidance meetings, they had sent a junior staff member, whilst the manufacturers of the air handling units had sent their managing director.

Nedin said: “It was a business opportunity. If the air handling people could seal the building they would sell lots of kit. There’s a lesson here, that we must not be complacent or we’ll soon have laminar air flow units and hepa filters everywhere!”

Make it mandatory
Cooper suggests that the only way to overcome similar knowledge gaps and ensure a continuous and comparable cycle of research is to make it mandatory that every pre-business case sets out its clinical policies and explicitly establishes clinical goals and objectives. “Rather than talking about world class facilities, let’s define it. As a practising architect, I’ve only once ever been given clear measurable objectives.

“The clinical objectives should be in every brief, so that we can apply the evidence to achieve them. Let’s also make it mandatory that there is a universal or comprehensive methodology for post-occupancy evaluation. Every facility over an agreed value should be evaluated on an annual basis in its first five years of operation, and then we will generate the evidence we need.”

In a final warning, however, Nedin says: “We have to be careful because even evidence can be ignored. Look at smoking. We package cigarettes that say, ‘give us your money, and we’ll kill you’ and people still buy them. But without good research to influence the guides, we’ll get guides that tell us the wrong thing, so we must never be complacent.”

Author: Marc Sansom is editorial director of the International Academy for Design & Health

Phil Nedin
2008-Present Director, Global Healthcare Business Leader, ARUP
2008 NHS Design Review Panel
2006-2008 President of the Institute of Healthcare Engineering and Estate Management (Now Past President)

John Cooper RIBA ARB
2002-2008 Director, Anshen + Allen; CABE Enabler
1981-2002 Founding Director,  Avanti Architects
1972 BA (Hons), Diploma in Architecture, University of Cambridge

©2018 All Rights Reserved. Website Design Graphic Evidence