The Center for Health Design


The Center for Health Design has a 20-year history of improving the quality of healthcare through improving the design of the built environment. Generally, the "built environment" comprises the design of structures and surroundings and how they affect human activities. In this case, it describes the way that design of a hospital impedes or enhances the activities of healthcare professionals in their contacts with patients and those who accompany them.

This entails exploring how architecture and behavior work together, applying best practices and carefully documenting things that go wrong, recognizing that in effect, design becomes prescriptive. Evidence-based design (EBD) is particularly well-suited to healthcare, because of the plethora of measurable outcomes that can be used to assure the best possible outcomes for the patient, the patient's family, and the hospital staff.

Why evidence-based design is increasingly important

Natalie Zensius, the Center's Director of Marketing and Communications, emphasizes that EBD is not just a marketing tool. There is a business and a financial imperative to truly improve safety and quality--the first of three internal revolutions in health care that have accelerated interest in EBD.

First, the quality and safety revolution. There is ample evidence of a measurable effect of the built environment on quality and safety. Interest in EBD has been on the upswing: between 2003 and 2008, about 1200 studies have been published (available for download on the Center Web site).

Second, the current system of health care is based on an acute awareness of errors and attempts to avoid the costs errors impose on finances, the struggle to avoid losing staff, and the human costs accrued by medical errors.

Third, reimbursement has shifted from resources consumed to outcomes achieved. Since many hospitals in this country are at the ends of their useful lives, there is much new construction going on. In short, EBD is a way to apply lessons learned through research to hospitals while they are being built.

Pebbles: the ripples in the healthcare water

To date, 65 hospitals in the United States and abroad have become involved in the Center's "Pebble Project." For the patient, this means keeping close records of environmental noise, looking at factors that affect distribution of medical care, pain levels among patients, distribution of medications; and for the hospital workers, looking for possible safety hazards. In short, looking for the gaps and seeing how they might be filled.

Pebble Project members and the staff of the Center not only look at literature and research to see where the evidence lies for using certain design features, but also take the further step to see if the hypothesized outcomes are borne out by reality. This is heart of the evidence-based design process, and ultimately what the Pebble Project is all about.

The evidence for evidence-based design

Amy Keller, an architect who is a Research Associate at the Center and its Pebble Design Strategist, described the seven different categories of evidence, starting with the goals and ending with a measure of how the outcomes are affected.

First comes patient safety, designing strategies that reduce medication errors. Amy cited a hospital in Michigan that built only single rooms and found an 11% decrease in medication errors. This Pebble Project hospital is now looking at the newborn ICU (NICU) environment, examining, for instance, the effect of decentralizing nursing stations. This study is now in the analysis phase; early findings indicate that nurses walk up to a mile less during charting activities.

In an Indiana Pebble (as they refer to their Project member hospitals), the notion of "acutely adaptable" rooms is being tested. .rucial physiological indicators are constantly read for evidence that the patient needs to be transferred to the ICU, with the goal of reducing unnecessary transfers that can be the source of errors.

Another important spatial modification being tested is the decentralized nursing station. No longer is there a single nursing station located at the end of a hall, but several smaller stations located near the patient rooms. While this arrangement seems more comfortable for the patients, Amy emphasized the interaction between the built and cultural environments: hospitals need to run training programs to ensure that staff had ample opportunities to interact and exchange information. As a consequence, spaces have to be allotted for staff to confer in comfort and in privacy.

The second category of evidence follows from the first: worker safety. This involves lighting choices, location of staff, and relieving staff of physical stressors. In an pilot study done for an Oregon replacement hospital, ceiling lifts were installed in the existing neurological and ICU units. Patients could now be taken to the toilet room or to a wheelchair by these lifts, reducing patient-handling injuries by 83%. In the new hospital, the added expense of installing the lifts will be recovered in 2 to 5 years by reduced worker compensation costs.

Rather than expanding the length of this article unduly, I'll summarize the remaining categories of research, and direct you to the Center's Web site for details. Building in response to the climate and possible climate change requires careful consideration of materials. Improving staff effectiveness, quality of care, and overall cost effectiveness are dependent on the final category of research: documenting the evidence-based design process itself. The Pebbles and other participating organizations are building a knowledge base that will be used to evaluate the effectiveness of the individual efforts that go into evidence-based design.

Just a few more details on EBD: first, not all EBD issues are easy to solve. For all the attractive features of the decentralized nursing station notion, it's not simple to harmonize location for patient service and for staff intercommunication. Second, the EBD outreach is not just to well-capitalized private hospitals in urban locations. It also embraces hospitals in rural areas that struggle financially. And, not only acute care settings are affected, but also those for ambulatory patients in long-term care.

The effectiveness of the Center is enhanced by its advocates: people in healthcare who believe in the EBD effort, staff and Board members who present its work at conferences (and at meetings like ours); and volunteers who send research results out to industry in an outreach effort.

Looking to the future

The Center has developed a home-grown educational project to spread EBD across the healthcare industry. Financed by the Robert Wood Johnson Foundation, the staff members have spent countless hours developing study materials for an exam aimed at educating persons in the healthcare community about EBD. The Evidence-Based Design Accreditation and Certification (EDAC) currently has 130 persons signed up in 35 countries to take the test who are already putting these principles into practice.