The increase in research related to the impact of the built environment on health care outcomes has increased at a rapid rate. There were 84 published studies in 1998 and the number had grown to 1,200 by 2008. Yet debate continues about the reliability of this evidence to inform our decision-making process.

Health care facilities are more interested in utilizing evidence-based design, although its usage remains inconsistent. Health Facilities Management's 2009 Hospital Building Report, for instance, indicated 22 percent were applying some evidence-based design concepts in all construction projects, while 40 percent said they were using them for some.

More and more facilities recognize that the built environment impacts patient outcomes, staff and the business model. Utilizing an evidence-based design process to validate assumptions can be a valuable way to inform the team and can act as the means to build on available research. In an evidence-based model, the design process is iterative. Ideas are advanced, explored and validated, which ultimately informs each aspect of the project. At times, further exploration may be needed or a new approach emerges.

Providing verification

It is difficult to isolate a single design decision to determine if it will affect an outcome. However, the health care industry is demanding verification that a given operational model or design element will be of value. Utilizing an evidence-based process can inform each decision as the health care project is designed.

This happened during the planning of Northwest Community Hospital (NCH) in Arlington Heights, Ill., when the decision to use double-leaf door entries into patient rooms was evaluated in mock-up simulations. The design feature was chosen after a literature search, and tours of other facilities indicated that it appeared to be a best practice.

Once the staff understood through simulation how easily a patient bed could be moved in and out of a room with one single, wider door, the decision was made to use one door, resulting in a net savings of $400,000 to the construction cost. While this outcome worked well for this particular hospital, it cannot be stated that it would be suitable for all, which is an important value the evidence-based approach adds to the process.

Interior design professionals are taught to investigate options and weigh the benefits of solutions. Yet, incorporating methods to test assumptions and utilize available evidence still is infrequent, inconsistent or conducted in isolation. The research methodology required by health care now insists on measurements of the results. Commitment to the rigor of an evidence-based process requires greater diligence and structure. It also requires exploring and verifying ideas without knowing where the outcome will lead. This presents an element of risk and the entire team needs to be ready to handle the impact of change the process might drive.

Collaborating on goals

Most projects start with a visioning or goal-setting session. Unfortunately, the goals often remain a static document with no means to measure success. And, without defining measurable goals, there is little opportunity to innovate and no way to measure success.

Ideally, the development of measurable goals should be a collaboration between the stakeholders and the designers. Facility leadership and the designers must understand the value of the pro­cess, be interested in reengineering operational models and business practices, and be committed to transformational culture change.

There are no standard tools to enable teams to use this process. While there may be a cost associated with some elements in the process, resolving issues before construction can save considerable money when the project is built and opened.

At NCH, the guiding principles were developed after the designers conducted a preliminary investigation. They benchmarked 100 hospitals that were incorporating innovative ideas regarding the approach to healing environments, different operational models, use of technology and sustainability. From this list, six hospitals were chosen to tour. Also around this time, the hospital conducted an all-staff brainstorming session called an Idea Exchange. This brought together experts from other industries, staff from across the organization and the community to discuss ideas and expectations in the context of the ideal hospital.

The guiding principles then were organized into a matrix document called the PEP Guide, which stands for principles-elements-processes. This enabled the team to identify design elements that could achieve each principle as well as define a measurement of success. The document was expanded with clinical input and identifying measurement tools, some of which were being utilized already by the hospital.

Specific metrics then were identified in a spreadsheet titled The Clinical Initiatives Scorecard. This document identified specific clinical, family, patient, staff and physician baseline and future satisfaction and financial data. It also identified the metric to be achieved, a target date for reaching this goal and the guiding principles that each metric would validate or confirm. The scorecard enabled the hospital to track the impact of new design and operational features against these metrics and formed the basis of post-occupancy research under way.

The Center for Health Design defines evidence-based design as "the process of basing decisions about the built environment on credible research to achieve the best possible outcomes." In this model, translating findings into program criteria is an iterative process that can utilize a number of tools and methods to analyze thoroughly a given design solution and arrive at one that best meets the goals established in the development of the guiding principles.

Testing the design

Among these tools, a mock-up room can become a true prototype to inform current and future projects. At NCH, mock-ups had been utilized in a previous project; however, in the recent project, the entire project team wanted to be able to test design assumptions in a simulated model. It was particularly valuable because the project called for repetitive functions for many of the rooms and the mock-ups enabled the team to evaluate all aspects thoroughly prior to construction.

The mock-up rooms helped to confirm the size and location of various elements within the rooms; inform decisions about types of lighting and materials to be used; and validate the nursing care model.

The mock-up started with taped-out areas on a warehouse floor. Walls were built and moved as the team worked through the user-group process. As the rooms became more refined, the team was able to resolve functional and operational issues, as well as those relating to patient experience. One significant decision was to increase the size of the exterior window in the room. Bringing the glass to the floor and expanding the window to span the width of the room gave patients a better view from their beds and more daylight.

Clinical operations, patient care delivery and safety were evaluated through simulations. The size and configuration of toilet rooms to allow for staff to assist the patient were tested. The patient room configuration was evaluated, leading to standardization of such components as the headwall and footwall. Following simulation testing, a double sliding door into the intensive care-unit rooms was selected over a triple sliding door.

The decentralized nursing model was tested as well. Clinical staff were able to simulate travel distances from the team stations to the patient rooms and the support core. Visibility of patients was a high priority for staff, so they were able to determine the most appropriate corridor observation window size, while at the same time evaluate the best way to address a patient's privacy.

The team station was constructed of modular systems and provided a more open environment, to which most of the staff were unaccustomed. The mock-ups enabled them to define the level of privacy and openness depending on the workflow, particularly for medication stations.

Three hundred and sixty-degree feedback was sought by inviting members of the community and the hospital staff to the warehouse, named the Vision Center, to provide input on the spaces related to family-centered care, amenities for families, staff's ability to be efficient and effective, and whether the environment supports healing. Such events became opportunities for fundraising.

The Vision Center also became a product-evaluation site. At several points in the process, the designers sought to validate these assumptions through hands-on testing and by conducting a return-on-investment (ROI) analysis. One such analysis related to the use of ceiling-mounted patient lifts. Nursing directors, organized into a stakeholder group called the PEP Council, conducted research on the impact of lifts on worker safety and incidents of injury, both internally and against national benchmarks. The first cost of including lifts was analyzed against the long-term costs to define the ROI. The process of engaging this stakeholder group was powerful. They had an interest in the outcome and could be engaged using resources not readily available to the design team.

This methodology was utilized throughout the process to inform decisions regarding several other features, including architectural details of transitions, coordination of acoustic and drywall ceilings, and selection of flooring material. In fact, the flooring material selection process incorporated a real-life installation of eight products. These were installed in a busy employee corridor that simulated the nursing-unit activities. Over the course of 10 weeks, the designers held evaluation sessions involving more than 200 staff, volunteers and visitors. They utilized a survey form to evaluate the flooring performance and appearance and the results were tabulated and analyzed.

In addition, designers gathered technical information regarding acoustical performance, rolling-load resistance, acoustic properties and maintenance costs as well as the replacement time frame so they could determine a life cycle-cost analysis.

The findings ultimately were incorporated into the project and gave both the designers and facility staff confidence that decisions were based on a thorough look at the evidence, and tested in simulated environments rather than relying solely on available research and past experience.

Promising results

The designers in association with the hospital now plan to conduct thorough post-occupancy research to validate their assumptions and add to the body of knowledge. The environment of exploration of ideas, and the tools and methods they used now have become part of their evidence-based process.

As a result of the building solutions employed at NCH, early findings show an increase of 14.5 percent in "Willingness to Recommend" criteria in surveys by South Bend, Ind.-based Press Ganey Associates Inc., which should translate into increased market share. The hospital's ability to recruit OB-GYN physicians, which translates into an increase in patients, has been positive as well.

Operational benefits seen thus far are greater control over loss of inventory and cost control for non-chargeable inventory as well as the ability to decentralize medication distribution to the bedside. One finding was that despite the 50 percent increase in square footage of each patient unit, there has been no increase in full-time equivalent employees.

Additionally, the cost savings related to the elimination of double-door access to patient rooms, and analysis of flooring products to yield a 15-year life cycle have been significant. The private patient-room model also has resulted in higher utilization rates, and increased the occupancy rate — from 64 percent to 86 percent.

Enhancing design decisions

Evidence-based interior design is enhanced when its conclusions are proven with such follow-up tools as simulations and room mock-ups.

Under such scenarios, past history, current theory and future uses all come together to make and confirm interior design decisions.

Jocelyn M. Stroupe, AAHID, IIDA, ASID, EDAC, is a principal at Cannon Design in Chicago. She can be reached at


Sidebar - Issues ahead

Despite the progress that has been made in evidence-based design, there are many issues that present problems for further advancing this development model.

The idea that research proves certain design elements can improve outcomes is very attractive. However, without proper analysis, it can be misused and misapplied. Every health care facility is unique and won't always choose the same solution. The ability to test these findings is essential in validating their application to a given project.

Similarly, teams frequently employ a just-in-time approach, resulting in a sporadic and unfocused effort. Many consider research to be an isolated activity that is conducted by a few researchers. With efforts such as these, there is little opportunity to innovate and to improve the overall health care environment. An evidence-based model demands more collaboration between facilities and designers to transform the environment of care.

Creating a culture that embraces the use of evidence throughout the process as well as one that enables thorough research to occur is important in setting the stage for the future. Research in the health care design industry still is evolving and, as such, the debate is healthy and necessary. The use of research will enable designers to evolve health care environments that can provide positive outcomes.


Sidebar - About this article

This feature is one of a series of quarterly articles published by Health Facilities Management ( magazine in partnership with the American Academy of Healthcare Interior Designers (