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Building the Evidence Base for Evidence-Based

DesignEditors' Introduction

Article in Environment and Behavior · March 2008

DOI: 10.1177/0013916507311545

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University of Florida
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Editorial Environment and Behavior
Volume 40 Number 2
March 2008 147-150
© 2008 Sage Publications
Building the Evidence Base 10.1177/0013916507311545
http://eab.sagepub.com
for Evidence-Based Design hosted at
http://online.sagepub.com

Editors’ Introduction

T he United States is starting one of the largest health care construction

programs in its history. A “perfect storm” of aging baby-boomers, higher
health care utilization by younger people, movement to the suburbs and
Sunbelt, competitive pressures to replace hospitals with semiprivate rooms,
and the need to replace antiquated 1960s-era Hill-Burton hospitals has led to
a health care building boom. Eighty-six percent of U.S. hospitals intend to
build a new building in the next 2 to 5 years, according to a 2006 random sur-
vey of hospital CEOs by Harris Interactive (Morrison, May 30, 2006, personal
communication). Healthcare construction is expected to exceed $76 billion a
year by 2011 and continue at a high level to 2020 and beyond (FMI, 2006).
At the same time, it is becoming clear that health care is unnecessarily
dangerous and stressful. According to the Institute of Medicine’s “quality
chasm” reports, as many as 98,000 people die of preventable medical errors
each year and 88,000 die of hospital-acquired infection (Institute of
Medicine, 2004). This is made worse by a 20% annual turnover rate of
hospital-based nurses, the first line of defense for patient safety and for
health care quality. When nurses leave, hospitals are often losing their most
experienced clinicians (Institute of Medicine, 2004).
A growing body of research is demonstrating that improved physical design
can help bring about dramatic increases in safety and quality—particularly
reductions in infection, falls, errors, transfers, nurse turnover and stress, and
increases in satisfaction (Ulrich, Zimring, Quan, & Joseph, 2006; Zimring,
Ulrich, Joseph, & Quan, 2006). This has led to increased interest in using
evidence-based design—design that is informed by a deep knowledge of
research and a commitment to add to that knowledge base through careful
evaluation and information sharing (Hamilton, 2003, 2004). Evidence-based
design is modeled on evidence-based medicine, where clinical protocols are
based on systematic reviews of the research literature that evaluate the qual-
ity and quantity of research supporting the efficacy of specific clinical deci-
sions. For example, evidence-based design has led the American Institute of
Architects to require that new acute care hospitals include only single rooms
in their 2006 Guidelines for the Design and Construction of Health Care

147

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148 Environment and Behavior

Facilities (Facility Guidelines Institute and the AIA Academy of Architecture

for Health, 2006). The guidelines are used as a code or reference standard in
42 U.S. states and by the U.S. federal government.
Major hospitals and health care systems are embracing evidence-based
design for everyday decision making. For example, the Center for Health
Design’s Pebble Program includes some 42 hospitals seeking to enhance health
care quality through evidence-based design. As the U.S. Military Health System
prepares to spend some $2.3 billion replacing Walter Reed and other hospitals,
Assistant Secretary of Defense for Health Affairs William Winkenwerder, MD,
issued a memo requesting that all design teams “apply patient-centered and
evidence-based design principles across all MILCON [military construction]
projects” (Winkenwerder, January 22, 2007). This will affect 77 hospitals and
500 clinics serving 9.6 million people worldwide.
Evidence-based design has the potential of helping make health care safer,
higher quality, and more patient-centered. However, effective evidence-based
design—a practice that can genuinely contribute to the wide range of com-
plex decisions involved with health care design—calls for a robust research
enterprise and a large body of valid and useful information. Compared to
some other settings, researchers focusing on health care have some advan-
tages. Healthcare decision makers are used to applying research and to
benchmarking. Hospitals typically record a wide range of outcome mea-
sures such as user satisfaction and health and safety statistics. However,
health care environments research is still in its infancy and reflects the
debates raging in Environment & Behavior more generally, such as how to
establish causal relationships in complex real world systems, how to do rigor-
ous research that is useful to decision makers hungry for information, the rel-
ative value of quantitative and qualitative methods and so on. This special issue
attempts to advance some of these debates and contribute to evidence-based
design by providing literature reviews, theoretical discussions, methodological
proposals, and empirical studies.
In the first article Rashid and Zimring explore how environmental qual-
ities such as noise, lighting, ambient temperature, and air quality affect
stress in both health care and workplace settings. They find that there is
more empirical research focusing on workplaces and that much of this work
has direct application to health care.
Johnson and Barach explore the role of qualitative research in health
care. They argue that qualitative methods are particularly suited to explor-
ing “high performance micro-systems” that reveal how people interact with
patients, other providers, technology, and the environments. They suggest
that qualitative methods can be used both as the basis of design and to

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 Zimring, Bosch / Editorial 149

establish quantitative hypotheses. Pati, Harvey, and Cason use a qualitative

methodology to explore the meaning of flexibility for a range of stakehold-
ers such as nurses, nurse administrators, dietary services, and others in six
U.S. hospitals. They conclude that flexibility, defined as convertibility and
expandablity, varies by role and that these varied definitions create a range
of design implications that go beyond typical conceptions.
Hall, Kyriacou, Handler, and Adams explore how physical distance and
the presence of a door in an emergency department predict how quickly
physicians assess chest pain patients in an emergency department, and find
that patients in rooms more than 25 feet from the main physician work area
and in rooms with a solid door are significantly more likely to have to wait
more than 10 minutes for an assessment. Shepley, Harris, and White study
how staff respond to private rooms in neonatal intensive care units.
Although this practice has been advocated as providing privacy for families
and reducing stress, it has also been criticized by some staff as making
supervision and monitoring more difficult. Shepley and her colleagues
compare staff self-reported stress and satisfaction in four neonatal intensive
care units in three hospitals, two with private rooms, and two without. They
conclude that private rooms generally reduce stress. Nanda and her col-
leagues assess the reaction of hospital patients and design students to art-
work. A growing body of research is showing that artwork in hospitals can
reduce stress and the use of pain medications (Ulrich, Lunden, & Eltinge,
1993). Nanda and her colleagues find that hospital patients rate nature
scenes as less stressful, whereas design students are less consistent in their
ratings, often preferring more provocative abstract art.
Craig Zimring
Georgia Institute of Technology
Sheila Bosch
Gresham Smith & Partners

References
Facility Guidelines Institute and the AIA Academy of Architecture for Health. (2006). 2006
Guidelines for design and construction of health care facilities. Washington, DC: Author.
FMI. (2006). FMI’s Construction Outlook—Fourth Quarter 2006 Report. Raleigh, NC: Author.
Hamilton, D. K. (2003). The four levels of evidence based practice. Healthcare Design, 3, 18-26.
Hamilton, D. K. (2004). Hypothesis and measurement: Essential steps for evidence-based
design. Healthcare Design, 3, 43-46.
Institute of Medicine. (2004). Work and workspace design to prevent and mitigate errors. In
A. Page (Ed.), Keeping patients safe: Transforming the work environment of nurses
(pp. 226-285). Washington, DC: National Academies Press.

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150 Environment and Behavior

Ulrich, R. S., Lunden, O., & Eltinge, J. L. (1993). Effects of exposure to nature and abstract
pictures on patients recovering from heart surgery. Paper presented at the thirty-third
meeting of the Society for Psychophysiological Research, Rottach-Egern, Germany.
Ulrich, R., Zimring, C., Quan, X., & Joseph, A. (2006). The environment’s impact on stress.
In S. O. Marberry (Ed.), Improving healthcare with better building design (pp. 37-63).
Chicago: Health Administration Press.
Zimring, C., Ulrich, R. S., Joseph, A., & Quan, X. (2006). The environment’s impact on safety.
In S. O. Marberry (Ed.), Improving healthcare with better building design (pp. 63-81).
Chicago: Health Administration Press.

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