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Whenever I give a talk about evidence-based design, I point out that the number of studies that link the design of the physical environment of healthcare to outcomes has grown from 80 credible studies in 1996 to more than 1,200 in 2009 -- which was the last time a full-blown literature review was done.

There's usually a physician in the audience who raises his hand and says, "Well.  That's nothing.  In evidence-based medicine, we have hundreds of thousands of studies."

That's true.  But everything is relative.  There are thousands more professionals doing credible research in the medical field than in the healthcare design field.  And lots more funding from a variety of sources with deep pockets.

Evidence-based design is still an emerging science -- but a rapidly growing one.  My guess is that the next literature review will find more than 2,000 studies that link the design of the physical environment of healthcare to outcomes.

What if we looked at quality vs. quantity? The EBD Glossary that was published in 2011 found 50 environmental variables that impacted 35 outcomes in these areas:

  1. Healthcare associated infections
  2. Medical errors
  3. Patient falls
  4. Patient satisfaction
  5. Patient waiting
  6. Staff efficiency
  7. Staff satisfaction

The first three on this list are in CMS's list of events targeted for reduction as part of its Partnership for Patients initiative. While most of what the 3,700 hospitals participating in the initiative are doing is process-oriented, they shouldn't ignore this piece (see my recent HCD blog post about this).

There's another category of research that I hope the next literature review includes -- operational savings as a result of building decisions.  Things like maintenance, energy, staffing, etc.

Some of the critics of evidence-based design also point out that there hasn't been much research validating new design innovations recently. That's the other side of the argument about quantity vs. quality.

What do you think?

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Kirk Hamilton

11 years ago

Your physician complainers and nay-sayers can themselves be criticized for failing to demand that clinical researchers thoroughly describe the settings in which clinical research is done. If clinical research regularly recorded the environmental information associated with their studies, we would probably be able to better link environmental and design factors to outcomes. They tend to say it isn't recorded because it is not relevant. I say show me the hard data that indicates it is irrelevant because I suspect the environment plays a far greater role than they imagine.

Sara Marberry

11 years ago

Good points, Kirk. While the environment may not be relevant in every type of clinical study, its impact on outcomes is definitely underrated.

Margie Snow

11 years ago

I think the good news is that there is a growing body of research; our clients are beginning to pay attention. Even if the clinical researchers are discounting the environmental impact, their COO is beginning to pay attention. Especially when it comes to operational expenses re. maintenance of the facility and energy costs. And their CEO is paying attention to the HCAHPS scores. As designers we appreciate the work being done in this field as it provides us with solid evidence to support our design process. And I will take quality over quantity any day!

Sara Marberry

11 years ago

Me, too, Margie. Me too!

Simon Lovegrove

11 years ago

I agree with the thoughts that you express. I and my company work in emerging markets to create high-end hospitals of the quality that you are used to. However, I have a but... to your hypothesis. Evidence based, by its description, has a habit of been backward looking. We need to balance that with innovation. New technologies particularly those related to primary care and prevention. We need to think about the lack of resources - the most obvious one being lack of doctors. The use of internet and mobile telephone technology creates opportunities and the design must at the very least have the flexibility to cope with the changes that are being forced upon us but which also create opportunities for change, more effective care and costs savings.
Take a look at the OECD information on hospital discharges and even more primary care consultations and you will see just how flexible we need to be.
I have learnt that one of the most important ways of addressing healthcare is to respect individual cultures - if one does not do that, neither staff nor patient will not take any sense of ownership. The challenge but also the opportunity of working in emerging markets is that one starts with a cleaner sheet of paper - it is easier to innovate and it is a must.

Sara Marberry

11 years ago

Thanks for your comment, Simon. I don't agree with you that the evidence-based design process is backward-looking. Yes, it's about basing building decisions on the best available evidence, but it's also critically interpreting that evidence and innovating new concepts that meet with today's models of care.

Simon Lovegrove

11 years ago

Sara, I did say that I agree with the thoughts but it needs to be mixed with innovation, which I understand to be your response. I am not a hospital architect but manager and we really have to innovate and as I say, there are really massive differences bettwen the evidence of one country and another. The architects that we work with use evidence but at the same time aim to build flexibility into the key spaces to allow for new ideas that will happen during the lifetime of the hospital.
We in the UK invented Private Finance Initiatives (sometimes called Public Private Partnerships)and these are used as a way of financing hospitals. I am not a fan. The problem is that PFI/PPP put far too much emphasis on the building and not enough on the operations. The contract tends to be 30 or so years and, therefore, the dynamic of hospital use is severely compromised. There needs to be the ability for regular change to respond to changes in the delivery of healthcare.
Nor do I like the PropCo/OpCo model favoured by Private Equity Funds. This too makes for inflexibility. So all you say is realistic but it does need to fit into the variety of contexts - finance cultural operational model etc.

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What's my story? I'm a healthcare and senior living design knowledge expert who writes and speaks frequently about trends and issues affecting these two industries. I'm also a strategic marketing consultant and content creator, working with companies and organizations who want to improve the quality of healthcare and senior living through the design of the physical environment. You can reach me at .

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