New hospital building focused on healthy, evidence-based design

The American Society for Healthcare Engineering of the American Hospital Association has expressed reservations about "Evidence-Based Design". Please refer to their Guidance Statement on Evidence Based Design below:

Considering Evidence-Based Design?

In the ever-changing world of healthcare design, the application of science and data collection to the design process has become more prevalent than ever before. One resulting new trend is the practice of "evidence-based design" (EBD). The Board of Directors and staff of the American Society for Healthcare Engineering of the American Hospital Association are concerned with potential misrepresentations of the EBD concept and the apparently widespread application of this new design methodology. This ASHE advisory provides an overview you and your staff can use to objectively evaluate claims related to the use of EBD in the project development process.

Overview
Evidence-based design can be seen as a by-product of evidence-based medicine (EBM) and the movement in healthcare to improve quality and increase patient safety. EBD is loosely defined by many as "the application of the best available evidence to facility design decisions." The "best available evidence" is understood by proponents to mean information that has been generated through some sort of academic or quasi-academic process (such as meta analysis or randomized controlled trials).

To this point, there is little to debate. After all, who would argue with the notion that design should be based on evidence? Isn't that what architects and engineers are hired to do?

Concerns regarding EBD are threefold:

The insufficient and untested nature of the "evidence" demanded and offered by EBD advocates as compared to the evidence available for evidence-based medicine
The questionable quality and small quantity of evidence available to support design decisions
The differences between how "evidence" is being used in building design and in medical treatment and care
To answer the question "Isn't that what architects and engineers always do," the academic field responds, "Yes, they do use evidence, but it is not the kind of evidence promoted by advocates of EBD, and it is used with much greater latitude given to creativity and exploration of new ideas." ASHE/AHA supports the idea of conducting experiments and research, adopting appropriate guidelines to support design decisions, and undertaking other measures intended to promote quality and safety in the healthcare environment. We urge caution, however, when statements are made that promise results based on little or poor-quality research.

Recommended Actions
As you are planning to enter into a design project, we suggest you give this subject further attention. Following this advisory is some background information in the form of an excellent research paper, "Evidence-Based Design in Healthcare: A Theoretical Dilemma," by Mary Stankos and Benyamin Schwarz of the University of Missouri-Columbia. In addition to reviewing this document, healthcare executives may want to ask the following questions when discussing evidence-based design with a design firm:

What does the designer understand EBD to be?
Has the designer read research study(ies) related to proposed design decisions that are said to be based on evidence?
What books or articles related to EBD or EBM has the designer read?
How certain is the designer that the desired outcomes of an EBD decision will be attained?
Asking these questions with an open mind will help separate the fact from the fantasy about the use of evidence in design and will keep expectations in line with reality.

Concerns About EBD
The three concerns about evidence-based design listed above are explained in more detail here:

First, evidence in medicine is developed in carefully controlled studies that form a body of information from which predictive theories can be developed. To date, no widely accepted protocols have been established for developing evidence for design and no recognized bodies have established themselves as capable of dispassionately reviewing and drawing conclusions from research studies. Without the ability to create predictive theories, EBD is reduced to the application of anecdotal conclusions about how we would like the environment to be rather than how we can expect the environment to be.

Second, the number of studies that relate to the environment of healthcare operations or healing is insufficient to support design decisions. In 2004 a Center for Health Design effort found what were described as "600 rigorous studies" (see reference below). An informal study by Kendall Hall, MD; Paul Barach, MD; and Ken Dickerman, AIA, ACHA, found approximately 1,200 studies of various quality levels. These are very small numbers when spread across the myriad factors involved in the design of the healthcare physical environment. Drawing predictive conclusions from a small number of studies in any particular area is as problematic in evidence-based design as it has been in evidence-based medicine.

The quality of the evidence presented by EBD proponents should be carefully examined. In evidence-based medicine, which is what evidence-based design is modeled on, serious disputes arise over the validity of some EBM studies. Even established evaluation consortia, such as the Cochrane Collaboration, are sometimes subject to strong criticism for a lack of care and integrity. It is unfortunate that some EBD proponents tout the results of a few loosely reviewed studies as facts that are beyond the challenge or interpretation of skeptics.

Third, the building design process is inherently different than the medical diagnosis and treatment process. In medicine, there are large volumes of patients with relatively similar complaints and physiology. In building design, every project is unique and, even though some components may be similar, healthcare design projects are invariably assembled in different ways. If the course of treatment prescribed by a physician doesn't work, the patient is usually available to come back for additional treatment. In a building project, the team gets one chance to get the treatment right. If the design isn't good, it's unlikely a postmortem will be conducted and the results subjected to careful scrutiny. These factors make building design a process that depends on highly experienced and competent practitioners, who can consider research recommendations and apply them to improve the quality of a particular project. A major concern about EBD is that it could foster a cookie-cutter approach to the healthcare design process, one in which guidelines and formulas are substituted for carefully considered design decisions.

To provide you with a much more detailed exposition on this topic, we are enclosing a copy of the article mentioned on the previous page ("Evidence-Based Design in Healthcare: A Theoretical Dilemma"). The use of this paper has been graciously granted by David Wang of the Interdisciplinary Design and Research e-Publication (IDRP), which is sponsored by the Interdisciplinary Design Institute of Washington State University (www.idrp.wsu.edu/index.html).

Reference

Ulrich, Roger; Craig Zimring; et al. "The Role of the Physical Environment in the Hospital of the 21st Century:
A Once-in-a-Lifetime Opportunity." Concord, Calif.: Center for Health Design, 2004.