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Most healthcare architects have developed a strong functional perspective in their work. It should therefore be a comfort to them to know
that important design concepts have, in fact, been tested and that there are data available to inform their medical designs. With serious
issues at stake, including sickness and healtheven life and deathmany architects welcome the emergence of data-based design.
On the other hand, serious designers might be concerned that evidence-based design represents a challenge that could limit their creativity
or freedom of choice. To fear loss of creativity, however, is to overlook the exciting challenges of continuously inventing responses to
emerging results and interesting new facts. This calls for an exceptionally creative and ever-changing interpretation of new data. Research
can offer complex and sometimes contradictory insights into the world of architectural design, encouraging designers to test new and
interesting ideas. The result is not reduced creative opportunities, but a commitment to observe the results of each design, and to use what
might have been learned on future projects.
There is also an understandable fear that evidence-based design can lead to cookbook architecture, suggesting a pattern of dull and
repetitious buildings stamped from the same mold of a bureaucratic prescription. The world of evidence-based design, however, lives closer
to the real world of scientific research, with its continuous search for the verifiable. Evidence-based design is not static, and does not easily
conform to fixed regulations that may soon be rendered ineffective by the steady stream of newly reported results.
The dean of Harvard's medical school reportedly tells each entering class that 50% of what they will learn is wrongbut we don't yet know
which 50%. Conscientious evidence-based practitioners should experience fewer such doubts as they make an increasing percentage of
their decisions on the basis of research. Rather than conforming to tightly limiting facility regulations, using loosely framed performance
guidelines should encourage designers to become increasingly aware of environmental research in healthcare.
Level-one practitioners: These architects and design professionals make a careful effort to design based on the available evidence.
They make an effort to stay current with literature in the field. The designer interprets the meaning of the evidence as it relates to his or her
project, and makes a judgment as to the best design for that specific circumstance. These designers are producing work that advances the
state of the art because they are learning from others and developing new examples for others, while delivering better designs for their
clients.
An example of a level-one project is an early design for Trinity Medical Center in Moline, Illinois. Watkins Hamilton Ross Architects (WHR)
worked with Trinity to develop a Planetree demonstration unit that provided family support amenities, including a family kitchen, den,
resource library, and foldout sleeping chair in the patient room (figure 2). Barriers to family involvement were also reduced in the
nontraditional nursing station design. The design concepts were based on benchmark reviews of other Planetree projects and interpretations
of published research.
This Trinity Medical Center patient room design, the result of patient
preference research, includes a foldout sleeping chair for overnight visitors
Level-two practitioners: Evidence-based practitioners at level two take another important step. Based on readings, they hypothesize
the expected outcomes of design interventions and subsequently measure the results. This level of attention makes design less subjective
and requires attention to new ways to design. At this level, the designer must understand the research, interpret its implications, and be able
to build a chain of logic to connect the design decision to a measurable outcome. This discipline reduces the number of arbitrary design
decisions in healthcare projects and delivers solutions linked to outcomes. It also raises the challenge of preventing bias from reducing
objectivity in the gathering and reporting of results. The evidence-based practitioner must strive for the truth and resist the temptation to tilt
the reporting of findings to emphasize success or downplay failure.
A level-two project of note was the replacement hospital WHR designed for St. Michael Health Care Center in Texarkana, Texas. The design
team hypothesized reductions in travel distance in the patient units. Travel distance was measured, once the design was constructed, and
demonstrated clear improvement. But the research also told a valuable story. In developing a pattern of decentralized nursing intended to
have the caregivers closer to bedside during rounds, it was expected that nurses would work in alcoves near clusters of beds on the busy
morning shift, spend more time at the two traditional nurse stations in the afternoon, and collapse their activity to a single station at night.
This pattern did not hold. Nurses found that proximity to the patient influenced their preferred work location on all shifts, and they used the
decentralized features on each shift.
Level-three practitioners: In addition to following the literature, hypothesizing the intended outcome of their design interventions, and
measuring the results, these designers report their results in the public arena. Publishing in the popular press or speaking at conferences
makes an important contribution to the field and advances the state of the art. It also subjects the designers' methods and results to the
scrutiny of others who may or may not agree with them. These practitioners soon learn they need to better understand research methods
and often seek some level of advanced education to promote greater rigor in their documentation of results.
I would submit that the speaking and publishing on healthcare design topics by members of our firm fits the level-three model. In my own
case, I gained insight into qualitative and quantitative research methods while earning an advanced degree in organization development
(see Relating Facility Design to Organization Design, p. 26, HealthCare Design, September 2003). My thesis was an exploratory case
study that investigated the relationship between the design of patient units at two hospitals and the relevant organizational performance. I
used quantitative data from several economic, clinical, and satisfaction indicators to measure the organizational performance, as well as
qualitative data from surveys and interviews recording the opinions of nurses, physicians, and executive leadership. I have since begun to
use methods developed for the thesis to evaluate other projects by our firm.
Level-four practitioners: Practitioners/scholars at this level perform the same tasks as those at the other levelsfollowing the
literature, hypothesizing the outcomes of design interventions, measuring the results, and reporting in the public arena. These practitioners
take the next step by publishing in quality journals that require review by qualified peers. They may also collaborate with social scientists in
academic settings who contribute to the formal literature. These level-four evidence-based practitioners are working directly in the field,
designing and building operating healthcare facilities, but they are also subjecting their work to the highest levels of rigorous review and
formally advancing the useful evidence in the field.
For example, working for The Institute for Rehabilitation and Research in Houston, WHR developed an innovative concept in their recent
master plan. The hypothesis was to include greenery and live plants within the physical therapy area, based on implications from research
about the role of nature in the healing process. Prior to developing a funded project, a Fellow in WHR's office performed a study of staff and
patient opinion about the type and amount of greenery that might be used (figure 3). In essence, the study sought staff/patient reactions to a
set of overlays of increasingly progressive vegetation on a typical gymnasium scene, as well as to a scene of natural vegetation for
comparison. The study was done with review by academic researchers from Texas A&M University who had participated in the original
research. The overlay comparison method was formally approved by the university's and the hospital's institutional review board (IRB). This
process fits the profile of a level-four project, and it resulted in heightened credibility of the research findings.
Useful Resources
Numerous sources of information that are potentially helpful to the designer are available. Delving into this body of material and taking time to
draw the proper design inferences from such diverse sources are challenging. Among the most directly relevant sources are the writings of
authors from the field of environmental psychology. While literature from the fields of medicine, nursing, management, engineering, industrial
design, and technology are helpful, the literature of psychology, sociology, anthropology, and economics are also relevant sources.
Conclusions
Architects are rarely taught about research methods and, as practitioners, most feel they do not have the training to fully understand, much
less perform, serious research. With a focus on tangible projects and standard contracts that offer no fees for research or postoccu-pancy
evaluations, few architects can see a way to make time for such unfunded efforts, no matter how worthwhile. If the client isn't willing to pay
for the evaluation, how can the architect afford to expend this effort? Perhaps the promise of better projects, each demonstrating measurably
better results for happy clients, makes the marketing case.
Evidence-based practitioners can feel good about proven results associated with their work and can be differentiated in the marketplace by
clients who seek higher performance from their costly projects. WHR has at times been chosen for a project in recognition of its researchbased design methods.
I believe that the use of research findings to improve design de-cisions comes naturally for many designers. Adding a level of rigor to what
we already do is a major element of the shift to evidence-based practice. It is the data gathering and postoccupancy research that frequently
are not funded. One useful approach is to enlist the client's available resources in the effort; i.e., the architect must learn to request needed
data that are already being collected by the client. The architect should try to convince the client of the value of post-occupancy data for
comparison. The best results will come from an unbiased, independent third-party evaluation.
Ultimately, architects may need to spend time and money collecting data for their own purposes. There is a clear business case for good
design, and an even stronger case for design linked to evidence of positive economic, clinical, and satisfaction outcomes.
Architects have a moral obligation to use the best and most reliable information available in the design of healthcare facilities. This is a
sacred public trust, granted with professional licensure. Like Pandora's box, which once opened could not be closed again, the moral
obligation of a practitioner, once evidence-based design has been encountered and understood, cannot be avoided.
Evidence-based design appeals to the scientific minds of physicians and other clinicians who are trying to practice on the basis of medical
evidence. It offers the prospect of improving clinical outcomes, and it gives patients and families the prospect of a higher-quality experience
in their healthcare encounters. The public, consumer groups, and payers are pleased with anything leading to more effective and lower-cost
healthcare.
Evidence-based design also appeals to the business-minded administrative leaders of hospitals. It offers them the prospect of re-duced costs
and/or improved organizational performance and can provide justification for some of the costly decisions made on their building projects.
Exemplary evidence-based architecture comfortably blends the architect's rich experience, understanding of classic design principles, and
creative inspiration with design decisions based on insightful interpretation of a broad range of research results. The trend toward researchinformed designs is profoundly transforming the field for the better. Architects should embrace evidence-based design with excitement and
begin to enthusiastically explore this fertile ground through serious study of clinical outcomes, economic performance, organizational
effectiveness, satisfaction measures, and their relationships to the physical settings of healthcare. The physical environments they design
will have a measurable positive impact in each of these areas. Evidence-based design signals the dawn of a promising and hopeful era in
healthcare architecture.
HD
D. Kirk Hamilton, FAIA, FACHA, is a founding principal with Watkins Hamilton Ross Architects in Houston, and leader of Q Group Advisors,
the firm's consulting division. He is a past-president of the American College of Healthcare Architects and the AIA Academy of Architecture
for Health. He is a member of the board of directors of The Center for Health Design and the Coalition for Health Environments Research. He
has authored and edited three books on health facility design and is currently working on a new book about evidence-based design for
critical care. He has recently completed a Master of Science in Organization Development at Pepperdine University. For further information,
call (713) 665-5665, e-mail khamilton@whrarchitects.com, or visit http://www.whrarchitects.com.
To comment on this article, please send e-mail to hamilton1103@hcdmagazine.com .
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