Evidence-based design has rapidly begun to play an important role in the development of healthcare facilities. The concept resonates with administrators and clinicians accustomed to evidence-based medicine. They are attracted to higher levels of design-process rigor and seek to reap measurably improved outcomes from their costly capital investments. As a result, design professionals are beginning to receive requests for proposals that ask about experience with evidence-based design.

Unfortunately, there are almost as many definitions of this aspect of practice as there are firms seeking new projects. Everything from rigorous research projects conducted under the auspices of university investigators to mediocre projects featuring carpet and indirect lighting have been described as “evidence-based,” and many blatant marketing descriptions are obvious self-promotions.

As evidence-based design for healthcare becomes widespread and sought after, how can design practitioners verify claims made about their expertise or the results associated with their work? How can healthcare executives and clinicians identify design professionals who have genuine expertise and find useful information on evidence-based projects?

Developing Consensus Definitions

A movement to develop wide agreement on definitions for evidence-based practice began in 2004 when The Center for Health Design offered an open invitation to participants at the HEALTHCARE DESIGN.04 conference in Houston to discuss the idea. A group of approximately 60 individuals attended. The need for consistency and development of a certification method, tentatively called Evidence-based Design Assessment & Certification (EDAC), were discussed. The idea of certifying individual practitioners and owners from many disciplines on the basis of an examination, and certifying projects on the basis of an objective scale, were also examined. Participants expressed strong support for the concept. Others who could not attend that session have since volunteered to participate.

A second national consensus meeting will occur during the HEALTHCARE DESIGN.05 conference, November 6-9 in Scottsdale, Arizona. Anyone interested is invited to attend and encouraged to participate.

The Center for Health Design promotes other initiatives intended to develop definitions and clarify the role of the environment in healthcare. The Environment of Care Task Force, a subgroup of The Center's Environmental Standards Council, is working to collaborate with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Health Care Guidelines Review Committee of the Facility Guidelines Institute (FGI).

Certification of Individual Expertise

One key concept is to identify and verify the expertise of a pool of interested individuals who have knowledge of evidence-based design definitions and theories, know where to find relevant evidence and how to interpret it for the purpose of design, and know how to use appropriate measurements to determine the pertinent results. There is a need to share a common understanding and language across the several disciplines that might interact on projects to achieve certification of individuals. Put another way, to make certification of individuals possible, an examination that can serve across multiple disciplines must be developed. Such an examination is not intended to be styled as licensure or to serve any specific group. It should be sufficiently universal to certify architects, interior designers, engineers, landscape architects, consultants, vendors, researchers, regulators, members of an owner's administration, and others interested in the fundamentals of evidence-based design

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Certification of Evidence-Based Projects

Designers have, of course, always used evidence from engineering science or the science of materials, as well as experience with fire protection, waterproofing, and so forth. Today's healthcare designers are now referencing clinical and social science research in addition to the real estate and building science evidence they have been accustomed to using.

The specification of a carpet on the basis of its antimicrobial characteristics or flame-spread rating relies on laboratory evidence. Does such a carpet selection merit describing the entire project as evidence-based? Another project might be designed in collaboration with a major research project in which the design is based on hypotheses about its influence on behavior and subjected to extensive measurement and peer-reviewed reports of the exhaustive findings. Surely such a project would qualify near the upper end of the range of evidence-based projects. But what are the relevant markers on a scale that ranges from little to overwhelming evidence, or from few decisions supported by evidence to numerous such decisions?

A broad consensus on the wide range of potential evidence-based projects and a common scale by which one project might be compared with another need to be developed. An interesting analogue is the U.S. Green Building Council's (USGBC) model for evaluating LEED projects. USGBC uses a list of categories relevant to green design and has offered a point scale within each category to identify a building's relative compliance with sustainability goals. It should be possible for the EDAC model to develop an analogous set of categories relevant to evidence-based design and to identify a point scale by which a project might earn certification.

Volunteers and the Tasks Ahead

Volunteers will be needed to help develop the EDAC model. Tasks include developing:

  • the organizational structure and a sustaining revenue model;

  • the model by which EDAC will certify individuals from many disciplines as competent in evidence-based practice or evaluation of evidence-based projects;

  • fair examination and study materials for the full range of individuals seeking certification in multiple disciplines;

  • the methods by which planned and completed projects will be objectively evaluated and awarded certification; and

  • a checklist of categories and measure-ments for scoring individual projects.

Volunteers prepared to perform these tasks are crucial to the work and to the development of a broad consensus. They should be a diverse group, representative of the intended wide base of multidisciplinary membership so that each group's voice will be heard as the model is developed. The Center for Health Design has received a generous grant from the Robert Wood Johnson Foundation to help support the development of the EDAC model and to put a project manager in place to focus the effort, guide the task forces, and sustain momentum.

If you are interested in helping to shape the future of evidence-based practice and join the others engaged in this important activity, please contact Jill Heshmati at The Center for Health Design (jheshmati@healthdesign.org). And please consider joining others interested in establishing consistency around the concept of evidence-based design by attending the meeting in Scottsdale this November, where the progress of the task forces will be reviewed and you can help launch the next phase of this historic effort. HD

D. Kirk Hamilton, FAIA, FACHA, is an Associate Professor of Architecture and a Fellow of the Center for Health Systems & Design at Texas A&M University. He has 30 years of practice as a hospital architect, including his role as a Founding Principal of WHR Architects. He is a past president of the American College of Healthcare Architects and the AIA Academy of Architecture for Health. He serves on the boards of The Center for Health Design and the Coalition for Health Environments Research.