Evidence Based Healthcare Design Rosalyn Cama.pdf
Carey Jangam
ROSALYN CAMA, FASID, is the president and principal designer of the evidence-based planning and interior design firm CAMA Incorporated in New Haven, Connecticut. CAMA Inc. was founded in 1983 and has completed many award-winning projects nationwide, including Yale-New Haven Hospital, New Haven, Connecticut; and American Cancer Center Headquarters and Hope Lodge in New York City. A frequent writer and speaker on the topic of evidence-based healthcare design, Ms.Cama was the 1998 national president of The American Society of Interior Designers and currently serves as chair of the board for The Center for Health Design.
Evidence-based design (EBD) is the process of constructing a building or physical environment based on scientific research to achieve the best possible outcomes.[1][2] Evidence-based design is especially important in evidence-based medicine, where research has shown that environment design can affect patient outcomes. It is also used in architecture, interior design, landscape architecture, facilities management, education, and urban planning. Evidence-based design is part of the larger movement towards evidence-based practices.
Evidence-based design (EBD) was popularized by the seminal study by Ulrich (1984) that showed the impact of a window view on patient recovery.[3] Studies have since examined the relationships between design of the physical environment of hospitals with outcomes in health, the results of which show how the physical environment can lower the incidence of nosocomial infections, medical errors, patient falls, and staff injuries;[4][5] and reduce stress of facility users, improve safety and productivity, reduce resource waste, and enhance sustainability.[6]
Evidence in EBD may include a wide range of sources of knowledge, from systematic literature reviews to practice guidelines and expert opinions.[7] Evidence-based design was first defined as "the deliberate attempt to base design decisions on the best available research evidence" and that "an evidence-based designer, together with an informed client, makes decisions based on the best available information from research and project evaluations".[8] The Center for Heath Design (CHD), a non-profit organization that supports healthcare and design professionals to improve the understanding and application of design that influence the performance of healthcare, patient satisfaction, staff productivity and safety, base their model on the importance of working in partnership with the client and interdisciplinary team to foster understanding of the client, preferences and resources.[1]
The roots of evidence-based design could go back to 1860 when Florence Nightingale identified fresh air as "the very first canon of nursing," and emphasized the importance of quiet, proper lighting, warmth and clean water. Nightingale applied statistics to nursing, notably with "Diagram of the causes of mortality in the army in the East".[9] This statistical study led to advances in sanitation, although the germ theory of disease was not yet fully accepted.
While healthcare proved to be one of the most prominent sectors to examine the evidence base for how good design benefits building occupants, visitors and the public, other sectors also have considerable bodies of evidence. And, many sectors benefit from literature reviews that draw together and summarise the evidence. In the UK some were led by the UK Commission for Architecture and the Built Environment, a government watchdog established by the Labour Party following its election in 1997 and commitment to improving the quality of the UK stock of public sector buildings. Other reviews were supported by various public or private organisations, and some were undertaken in academia. Reviews were undertaken at the urban scale, some were cross-sectoral and others were sector based (hospitals, schools, higher education). An academic paper by Sebastian Macmillan [20]) gives an overview of the field as it was in 2006.
In New Zealand, a landmark review [24]was supported by the Ministry for the Environment. The study categorised the evidence as conclusive, strong, suggestive or anecdotal, and also noted the difficulty of establishing causation since various design elements may be found in combination with other features. The authors state that urban design is context-specific and cautions against automatically adopting what works elsewhere in New Zealand.
A comprehensive review of the literature was undertaken in 2005 for the Design Council.[31] It concluded that there was evidence for the effect of basic physical variables (air quality, temperature, noise) on learning but that once minimum standards were achieved, further improvements were less significant. The reviewers found forceful opinions on the effects of lighting and colour but that the supporting evidence was conflicting. It was difficult to draw generalizable conclusions about other physical characteristics, and the interactions between different elements was as important as single elements.
In the higher education sector, a review by CABE[35] reports on the links between building design and the recruitment, retention and performance of staff and students. Fifty articles are reviewed, and five new case studies reported.
The offices sector has been widely studied with the major concerns focusing on productivity. A study in 2000 by Sheffield Hallam University[36] reported that apart from surveys of occupants of individual offices, the evidence base on new workplaces was mainly journalistic and biased towards interviews with successes and failures. Some companies claimed that new spatial arrangements led to reduced costs, reduced absenteeism and easier recruitment, faster development of new ideas, and increased profitability. But others reported the exact opposite; and the reasons for this remained unclear.
CABE and the British Council for Offices published a joint study in 2005.[37] The paper reports that four main issues have been studied: the largest is environmental and ergonomic issues related to the comfort of individual office workers; secondly research on the efficiency with which office space is used; thirdly adaptability and flexibility and finally research related to supporting work processes. The report is critical of the disproportionate focus on the performance of building services compared with other aspects of buildings.
There is a growing awareness among healthcare professionals and medical planners for the need to create patient-centered environments that can help patients and family cope with the stress that accompanies illness.[38] There is also growing supporting research and evidence through various studies that have shown both the influence of well-designed environments on positive patient health outcomes, and poor design on negative effects including longer hospital stays.[38]
Using biophilic design concepts in interior environments is increasingly argued to have positive impacts on health and well-being through improving direct and indirect experiences of nature. Numerous studies have demonstrated improved patient health outcomes through environmental measures; exposing patients to nature has been shown to produce substantial alleviation of pain, and limited research also suggests that patients experience less pain when exposed to higher levels of daylight in their hospital rooms.[39] Patients have an increased need for sleep during illness, but suffer from poor sleep when hospitalised.[40] Approaches such as single-bed rooms and reduced noise have been shown to improve patient sleep.[40] Natural daylight in patient rooms help to maintain circadian rhythms and improve sleep.[41]
According to Heerwagen,[42] an environmental psychologist, medical models of health integrate behavioral, social, psychological, and mental processes. Contact with nature and daylight[43] has been found to enhance emotional functioning; drawing on research from studies (EBD) on well-being outcomes and building features. Positive feelings such as calmness increase, while anxiety, anger, or other negative emotions diminish with views of nature.[44][45] In contrast there is also convincing evidence that stress could be worsened and ineffective in fostering restoration in built environments that lack nature.[45]
Few studies have shown the restorative effects of gardens for stressed patients, families and staff.[46] Behavioural observation and interview methods in post occupancy studies of hospital gardens have shown a faster recovery from stress by nearly all garden users.[47] Limited evidence suggest increased benefits when these gardens contain foliage, flowers, water, pleasant nature sounds, such as birds and water.[46][47][3]
EBD is closely related to performance-based building design (PBBD) practices. As an approach to design, PBBD tries to create clear statistical relationships between design decisions and satisfaction levels demonstrated by the building systems. Like EBD, PBBD uses research evidence to predict performance related to design decisions.
The decision-making process is non-linear, since the building environment is a complex system. Choices cannot be based on cause-and-effect predictions; instead, they depend on variable components and mutual relationships. Technical systems, such as heating, ventilation and air-conditioning, have interrelated design choices and related performance requirements (such as energy use, comfort and use cycles) are variable components.
Evidence-based medicine (EBM) is a systematic process of evaluating scientific research which is used as the basis for clinical treatment choices.[48] Sackett, Rosenberg, Gray, Haynes and Richardson argue that "evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients".[49] It is used in the healthcare industry to convince decision-makers to invest the time and money to build better buildings, realizing strategic business advantages as a result. As medicine has become increasingly evidence-based, healthcare design uses EBD to link hospitals' physical environments with healthcare outcomes.
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