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Inquiry: Methods Of Our Madness

Evidence-based design (EBD) is the new buzz-word in the field of design and health. Jacqueline Vischer asks five leading experts to give their reflections on the merits of EBD relative to research-based design.

Jacqueline C Vischer, Professor of Design, University of Montréal

The idea that immediate, in situ identification of space-use research problems pertinent to an ongoing design process can lead to basing design decisions on empirical research outcomes is immensely appealing, because the one thing no design project has today is time.

And more conventional design research takes time – to fund, to design, to do and to interpret. Post-occupancy evaluation (POE), for example, is a favoured approach to design research where the systematic study of users’ responses in buildings generates information designers can apply to programming and new design. But POE takes time, and in taking a broad-brush approach to building performance and users’ needs has often failed to yield results directly applicable to a specific project.

But saving time is not always a good thing in research. Taking short cuts can compromise the quality of research. Defining the research problem is often a study in itself, and the wrong definition of the problem will yield useless results – no matter how good the research. Who does the research can also muddy the waters: everyone is familiar with researcher bias and the effect researcher expectations can have on results.

So the positive side of evidence-based design (EBD) is that it is relevant, it is practical, it is fast and it can be applied in real projects. The dark side of EBD is that time and other practical limitations might have ethical implications, leading to a compromise of research protocol or erroneous methods of data collection and analysis.

By adopting EBD as an updated approach to space-use research, it is important, therefore, not to substitute it for conventional research, which maintains its value in our high-speed and high-pressure culture. And conventional design research includes more than laboratory studies of human behaviour – there is applied research, field research and also action research. The lesson to learn is that design research is increasingly rich and complex, and EBD can, in the right time and place, be one of the tools at our disposal.

Faye Le Doux, Vice President, Ellerbe Beckett

Over time, we have charted the evolution of healthcare design and can attribute many changes in design to the improvement of patient outcomes – smaller wards lead to decreased infection and mortality rates, increased patient satisfaction and better staff efficiency. It is difficult to identify whether evidence of poor outcomes in existing facilities became the conscious or informed basis for design improvement or if the changes were made intuitively – but the results were positive regardless.

Now, resulting from the need to replace outdated hospitals, ageing of the baby boomers, advances in technology and the shortage of nursing staff, the US is facing one of the largest hospital building booms in history. This gives healthcare designers an unprecedented opportunity to re-think hospital design.

Guiding the change will be rigorous research linking the hospital’s physical environment to patient and staff outcomes – or ‘EBD’. And, although there is a great deal of information and research available to the designer and the informed client, a critical mind must determine how to use it to develop an appropriate solution to a problem. In the final analysis, EBD should result in measurable improvements in clinical outcomes, staff productivity and turnover, patient satisfaction, and financial performance.

Phil Nedin, Global healthcare business leader, ARUP

The therapeutic environment is, fundamentally, related to the creation of the ‘quality of space’. Place-making in this respect involves many elements of design, including clear signage, uncomplicated wayfinding, acoustic and thermal comfort, connection with the external environment, views that create calm in patients and pleasure for staff, a secure environment, a non-threatening scale, cleanliness to achieve a positive reduction on the transmission of healthcare-acquired infection, space planning, and single rooms that increase levels of privacy and dignity.

There are three key groups that benefit spiritually and physically from well-designed clinical facilities – the patient, the visitor and staff. Yet, the experience of each group differs markedly, particularly in relation to the time spent in the facility.

A patient’s length of stay in an acute facility is typically limited to an average of four days. Their visitors will be subject to a similar attendance regime. It is the staff that enjoys the longest stay – suggesting that it is this community who should have the biggest say in the design of an environment.

Unfortunately it is often difficult for staff to visualise what good designers can create for them in terms of spatial quality, ambience and comfort. Hence, the practice of post-occupancy surveys or audits is an essential part of the learning process for both staff and designers. A research project, for example, that comprehensively evaluated existing exemplar projects from a user’s perspective would significantly enhance the knowledge base and allow designers to present to staff, patients and carers about to embark on construction projects, examples of the components parts of a therapeutic environment. The new project in turn would be assessed and become part of the next wave of evaluations.

Susan Francis, Special advisor for health,
Commission for Architecture and the Built Environment


Ten years ago we pondered, does the environment contribute to healing? Now, we ask, in a much more specific way, how do particular aspects of the design of the physical environment impact on patients’ outcomes, experience and on organisational effectiveness?

Research and EBD have helped us to get here. The evidence base for design in healthcare has typically drawn on three approaches: scientific studies, like medical drug trials, isolating single variables to connect environmental features with specific outcomes; social science methods that seek to establish perceptions and levels of user satisfaction; and thirdly, design-led enquiry that has developed ideas about the therapeutic nature of the environment and, more recently, the ability to measure and rate the quality of design.

There is no doubt, from where I now sit, as chair of NHS Design Review, the quality of the design of healthcare environments has improved. This is not solely due to research activity. This kind of culture change requires huge effort on many fronts including government policy, design practice, procurement requirements and an informed client.

But what EBD and research can do is to inform the next generation of healthcare environments, by providing the ammunition needed to argue the case for investment in good quality design; better understand what really makes a difference; and create feedback from projects in use. 

Cyndi McCullough, Senior vice president, HDR Architecture

While often used interchangeably, research-based design (RBD) and EBD have some distinguishing differences. RBD is more rigorous and is based on studies using comparative research instruments and outcome measures. EBD is rooted more in healthcare provider observation and anecdotal evidence – no less important. Both are focused on providing the best possible healing and safety-focused environments.

Evidence-based medicine has been around for over 30 years. Research-based results often take 15-20 years to transition from research outcomes to actual medical practice. Roger Ulrich’s 1984 landmark study on evidence-based design launched an avalanche of some 600 research studies on such healing design features as neonatal intensive care unit (NICU) lighting, sinks in rooms and infection control.

Conversely, there has not yet been true research conducted on the benefit of same-handed rooms, but it is a concept that is gaining popularity, based on the principles of EBD rather than RBD. The Center for Health Design stands in the forefront of the EBD movement through its multi-year research effort with other healthcare organisations interested in providing design that fosters optimum patient healing and safe environments. HDR is proud to have designed some of those organisations’ healthcare facilities.

Mike Nightingale, Founder, Nightingale Associates

Carefully documented and fully verified research is the key foundation stone for EBD, enabling designed facilities to be used as test beds for further research. The inspirational dynamic of excellent creative design can provide the ‘quantum leaps’ in the evolving relationship between research and EBD. To capture this, post-project evaluation, which is rarely carried out systematically, needs to be properly funded and formally included in private and public healthcare procurement processes.

The success of EBD is reliant on the quality and appropiateness of the evidence used. The evidence also has to be correctly interpreted for the specific design challenge. The research base for EBD needs to be constantly evolving to keep pace with social, medical and scientific advances and needs to fully address the huge design challenges caused by climate change and the differing circumstances of rich and poor. The ultimate prize is universally available current research that is constantly being enriched by fully evaluated completed projects.












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