Evidence-based design the best model for health care?

[cougarnurse]

I know we've all heard about EB research, etc. Saw this article, and want to know what you think: Process: Is evidence-based design the best model for healthcare practices?

In late August 2008, shortly after the American Institute of Architects (AIA) named the winners of its first health design awards, The Wall Street Journal ran a story on design improvements in patient-treatment areas in its Informed Patient column. Although the article addressed the heightened focus on patients as a positive development, linking many of the design innovations to what author Laura Landro referred to as "the nascent field of 'evidence-based design,'" she noted, "Evidence-based design is not without controversy." The critique turned on the use of evidence-based design as a "marketing tool" often deployed without sufficient research to support design decisions.

While it is true that evidence-based design is an emergent model for design practices, there is a long and well-documented history of studies that confirm the influence of the physical environment on human activity and behavior, and of the physiological effects on patients. As a growing body of research continues to demonstrate that the quality of space in healthcare buildings affects the outcome of medical care, architectural and interior design has become an important part of the healing process. Further, healthcare design professionals are increasingly challenged to provide environmental design solutions that not only contribute to therapy, but also create safe environments that are supportive of patients and staff.

Still there are healthcare planners and designers that make critical design decisions based upon intuition—designs assumed to be better, instead of decisions based upon rigorous research with results that prove the superiority of the decision. A completed design may or may not result in a healing environment. A healing environment, however, can be identified by evidence from measurement and results.

So, what is evidence-based design? D. Kirk Hamilton, founding partner of WHR Architects, associate professor of architecture and fellow of the Center for Health Systems & Design at Texas A&M University, and pioneer in the field, defines evidence-based design as "the deliberate attempt to base design decisions on the best available research evidence. Evidence-based designers make critical decisions, together with an informed client, on the basis of the best available information from credible research and the evaluation of completed projects."

Not that the approach is new—the practice of gathering evidence to demonstrate success or failure in building systems design has been the most reliable methodology for solving complex design problems since man first put up a wall. What has evolved is the professionals' ability to research the most effective solution and then to measure the results. With a rigorous research process that includes relevant literature search, documentation and measurements from system failure analysis, post-occupancy evaluations, benchmarking best practice sites, as well as other shared findings, design professionals are simply better prepared to make design decisions.

It's no wonder that healthcare designers have been among the first to adopt the evidenced-based design model. In healthcare facilities design decisions are tested by life and death situations everyday. Beyond the obvious call for accountability on the part of owners and the public-at-large, professional knowledge carries a moral obligation to represent the best interest of society with an accepted standard of practice.

When designing an emergency room, a nurses' station or a patient room, the architect or interior designer has the obligation and the opportunity to address critical issues of safety and healing that effect everything from the mitigation of stress to the provision of comfort, from operations to technology, from the placement of sinks to the availability of views. The good news is that these choices need not be subjective. Today's practitioners have access to an incredible and expanding store of research to help them develop rational hypotheses. With healthcare's focus on tracking results—be it turnaround times in the ER, the number of patient falls, or prescription errors—developing measurements of post-occupancy effectiveness is a logical extension of the design effort.

While the benefits of evidence-based design for patients and staff are increasingly recognized, the model also provides design staff with a framework for decision-making that promotes thoughtful and innovative design. Young architects and interior designers flourish in a robust practice model that offers a clear methodology and the ability to see the results of their initiative in measurable improvements to the health and safety of patients.

Evidenced-based design is being embraced by leading hospitals internationally because the stakes are so high (financial investment, patient/staff safety, quality of care, customer satisfaction, staff recruitment/retention, clinical operations, etc.). Savvy hospital executives know that design is a very important component for a successful healthcare business enterprise. Many realize there is value added for well thought out design solutions, which are based upon credible sources of information. For these reasons, design professionals should expect hospital preference for firms who truly practice evidence-based design.

Does your facility rely on this? How does it affect your practice? Does it help? Hinder? Are you even asked?

[Ricu]

We at our facility like to think we follow evidence-based everything. Maybe we do and maybe we don't, I'm not really sure. I think we're on the mark when it comes to evidence based practice but now on the other hand, evidence based design?
I live in an area where ther are community hospitals in nearly every town and medical centers less than an hour in every direction so the competition is steep. This is demonstrated in a lot of ways but none so obvious as appearance of the facilities themselves, followed closely by sevice delivery. About a dozen years ago, there was a renaissance among the hospitals which began just with the unit "facelift". There was wallpaper, paintings, incandescent lighting, area rugs, upholstered furniture in the sitting areas, hospitality carts and so on. Furthermore, the medical equipment at the headboard was discreetly hidden behind drapes, linen carts and medical waste went into cabinets and the linens themselves no longer white but colored and printed. Once the physical transformation happened, much needed attention was put into food. Emphasis was placed on flavor and eye appeal and several facilities hired chefs. End result, welcome to the Hyatt Regency.

My feeling on this is that it can only help so long as it doesn't interfere with the delivery of quality medical care. The ICU that I work in was remodeled about four years ago and the public loves it. We have cherry wainscotting, rich gold and sage walls, patterned linoleum on the floors in complementry shades. In the rooms there is cherry congoleum, (looks like hardwood) flooring, equipment built into cherry cabinetry, lights on dimmer switches and the list goes on. Problem? The dark floor shows everything. Dark walls and floors absorb light so it's difficult to do procedures. So much so that we have staff come in with flashlights- I'm not kidding. We do have a "procedure" light overhead but since it cannot be focused, it is only good for mouthcare. I call it the tanning light. Since we've been in the new space, I've asked for a surgical procedure light on wheels but been told that it's not in the buget. The monitors are discreetly placed in the corner- so much so that it's hard to see them around the cabinets and when other equipment is brought into the room. Cables must be extra long and hang sometimes painfully on the patient. Often they end up taped to the bedrail or slung through extra IV hooks to take up the weight. Tell me that doesn't take away from the look! Trash is hidden in a cupboard and contaminated waste is not in the room but bins must be brought in from the dirty utility room. Does this improve ambiance? Sometimes. Does it compromise quality care? Sometimes.

This begs the question alluded to in the article which is, do the architects consult with the professionals who work in the space or do they at least research design plans currently in use, in short, see the evidence? I'm not talking about the lobby or waiting room, but the dirct patient care areas. Personally, I like the look of our unit but hate working in it. There is increased potential for patient injury and asceptic compromise which can be directly connected to design. Had the nursing staff been invited to preview the design while it was on paper, modifications may have been possible which could've prevented many of these problems and likely not compromised asthetics. Instead, we work in this opulent environment, maneuver around critical design flaws and continually hear about how beautiful it is.

R

[cougarnurse]

The non-for-profits have to spend their cash somehow, I suppose, but let's be honest: when you're in the middle of a code or other crisis, what does the fancy decoration count for?

Like you said, RICU, the room does get crowded. And contaminated waste containers come from dirty utility? Talk about cross contamination!.

[Ricu]

Originally Posted by cougarnurse

The non-for-profits have to spend their cash somehow, I suppose, but let's be honest: when you're in the middle of a code or other crisis, what does the fancy decoration count for?

Like you said, RICU, the room does get crowded. And contaminated waste containers come from dirty utility? Talk about cross contamination!.

It can get pretty tricky. We have to bring carts into the room since we really have little at the bedside. It's good that the OR is around the corner because I've called them for that portable light on more than one occasion and I'm glad to say that they've been quick to respond. We've learned to work around it but it's taken a lott of adaptive creativity.

R

[cougarnurse]

As you mentioned....did the planners even consider those of us at the bedside? Seems like it takes away from patient care a bit.

[Ricu]

Yes, there is a lot more to performing patient care now that the unit is designed for looks. It's pretty clear to us that nursing input was never considered. I think that our admin. and the architects/designers/ contractors took a lot for granted in terms of their design functionality because it's clear that no "real" research was done. Well, maybe Martha Stewart was consulted for the color palette...

R

[cougarnurse]

One would think puke green would hide alot of 'ills'.....

[Ricu]

Originally Posted by cougarnurse

One would think puke green would hide alot of 'ills'.....

Remember the good ol' days when, before fluorescent colors, nursing units were tiled in either puke green or bile yellow? If you were lucky, your unit was just sterile white.

R

[cougarnurse]

Heck of a lot better to clean, and who'd heard of MRSA back then? More food for thought.

[Ricu]

Originally Posted by cougarnurse

Heck of a lot better to clean, and who'd heard of MRSA back then? More food for thought.

Pointing again toward evidence based practice- triple antibiotic coverage until organism isolated. What new resistant germ next?