Research-based Design: Breaking Down the Options
The evidence-based design (EBD) movement is inspiring thousands of architects to share knowledge and innovations from research, making architecture more relevant to health system clients and to the national healthcare reform discourse.
With each new or renovated healthcare facility, contributing factors to care can be measured, performance goals can be set, simulations and prototypes can be created, and results can be tracked and fed back into the design process for the next iteration—all to enable better outcomes and experience for patients, which are more efficient and less costly for the system.
But there are questions among the A/E community about how research is conducted and what level of rigor is possible, and questions about how findings can be generalized and applied across the industry.
To address these concerns, the AIA Academy of Architecture for Health (AIA AAH) formed a committee to define the role of research and evidence, influence the industry toward the type and extent of research that practitioners need, and reinforce the idea that if we measure the performance of what we design, we will validate or further define the body of knowledge.
We’re also learning to respect the rigor of research—its quality, design, and methodology. And we’re seeing the relevance and applicability to the commitment in the healthcare industry to become more efficient and accountable in the delivery of care.
Types of research studies best suited for architecture
The architecture field at large has been grappling with the responsibility to demonstrate to clients the reasons and evidence for design decisions. While research exists, questions always arise on what type of research is most useful to architects. Below are four types of research studies that yield relevant insights.
Case studies are commonly used to produce a catalog of facility examples to understand current trends across comparable rooms, units, or facility types. What is not common, however, is a coordinated effort toward building a standard approach, methodology, and format for case studies.
If a standard could be determined, a collection of cases could yield a database that expands over time. Architectural case studies usually document factual, objective information pulled from existing literature, archival data, floor plans, as well as the design intent and key drivers from the project team.
Some case studies take it a step further and include an evaluation component on targeted environmental factors collected from site observations and interviews with key stakeholders.
If an evaluation component is included across multiple cases, a modest performance-oriented database can yieldbest practices and informed benchmarks for new construction and renovation projects. Metrics related to size, space allocation, cost, net-to-gross factor, and distances are some examples of what could be compared.
Post-occupancy evaluations (POEs)
The focus of POEs is on measurement using a set of performance indicators or metrics and a variety of data collection efforts. POEs have been used in healthcare design particularly to assess the strengths and weaknesses of an individual facility in relation to original design intentions and resultant performance outcomes.
While the intentions are worthy, the issue—similar to case studies—is that there isn’t a coordinated effort that coalesces around a standardized framework, methodology, metrics, and data collection tools.
The Military Health System has embarked on building a facility performance evaluation program using POEs to address this gap in the field. Once strengths and challenges are determined, priorities may be established to take corrective action in terms of design, policy, and/or operational improvements.
Follow-up evaluations could occur to determine if the intervention employed was successful and achieved the desired effect.
Prototyping can be used to study how a design may impact outcomes of interest, such as functionality, safety, or how the design incorporates the latest lighting, information technology, controls, or finishing materials.
Prototyping typically involves a process where design ideas are transferred first into three-dimensional virtual models and then full-scale replicas of the built environment. As opposed to a casual mock-up, prototyping research involves a systematic process of studying outcomes in relation to design concepts in an iterative design and evaluation process. Through this process, lessons learned are used to create higher fidelity models in subsequent design refinement cycles.
An example of prototyping research in the academic realm is Clemson University’s latest patient room prototype. The Patient Room 2020 project is a collaborative effort started between Nxt Health and Clemson. Another example is The University Medical Center at Princeton’s functional inpatient room mock-up.
Focused research studies
Most research studies published within the healthcare design literature databases are conducted by researchers from allied fields to architecture. There has been a recent push to increase the number of studies supporting architecturally relevant questions. For example, the Academy of Architecture for Health Foundation and the AIA AAH have joined forces to sponsor significant practical research for the architectural profession. Since 2005, a variety of topics have been supported, such as:
- Impact of single-family NICU rooms on family behavior
- Validating new acoustic guidelines for healthcare facilities
- Area calculation and net-gross ratios in hospital design
- Optimizing toilet location for assisted toileting
- Patient room handedness and caregiver body mechanics.
The practitioner’s perspective on architects’ application of research
The act of research-based design is an opportunity to advance the discourse between architects and health system clients for more intelligent and thoughtful health facilities. The AIA AAH research committee is working to encourage this discourse. The mission is threefold:
- Identify research knowledge needed by healthcare architects
- Support creation of new research knowledge
- Disseminate research knowledge to practicing architects.
We first focused on the “identify” aspect by creating a research agenda. In the past decade, this research has primarily centered on the topics of patient/family experience and satisfaction; staff experience and satisfaction; quality (generally concerned with customer perception); and safety (both patient and staff). As the positive impacts of research-based design are increasingly recognized, we need to identify areas where more research is needed. This research agenda will be useful for architects and encourage the research industry. It’s proposed to develop this broader agenda in detail to include the following areas:
- Staff workplace effectiveness and efficiency
- Planning typologies
- Return-on-investment concepts
- Lean prototypes
- Facility effects of emerging care models (medical home, more mid-level providers, wellness promotion, etc). li>
AIA AAH surveyed groups of architects in 2011 to test the agenda with practitioners. In the surveys, we asked respondents to indicate the relative importance of various types of research knowledge to informing their design practice. The following priorities were identified as the highest:
- Decentralized IP nursing facilities’ effect on recovery outcomes, error rates, direct care time, and communications
- Electronic medical records various workstation types’ effect on staff effectiveness
- Planning typologies relationship to staff effectiveness
- Optimum key room sizes relationship to staff effectiveness
- Various design strategies’ influence on fall rates.
In order to successfully support this expanded agenda, funding is needed. Discussions for this include legislative initiatives, existing government research funds, and private industry support. The AIA AAH and AAH Foundation are committed to increasing fundraising in support of research. The AAH research committee has developed a conversation with a network of stakeholders in a three-times-per-year gathering of other organizations engaged in the topic of research focused on healthcare environments. It includes the American Society of Healthcare Engineering, Facility Guidelines Institute, universities, health systems, and others. The goal is to discover how to work in concert rather than in parallel to support funding for the most needed research.
To disseminate knowledge, there must be a systematic way to catalog and access the studies that are available now and in the future. Architects designing healthcare facilities today want to apply research, but have difficulty knowing where to find it. To address this need, AAH, working with The Center for Heath Design, has sponsored The Knowledge Repository, a searchable database of research.
So far, 100 research items have been “translated” with abstracts and design implications, and have recently been made available on The Center’s website (www.healthdesign.org), with the idea of continuously expanding it over time as additional funding is made available.
With these initiatives, the Academy of Architecture for Health is committed to powering the research-based architectural practice of the future.
The authors are members of the AIA Academy of Architecture for Health Research Committee. Dina Battisto, PhD, Assoc. AIA, is associate professor in the Architecture + Health Program, School of Architecture at Clemson University and can be reached at firstname.lastname@example.org. Tom Clark, AIA, EDAC, is principal for planning and design at Clark/Kjos Architects and can be reached at email@example.com. Ron Smith, AIA, ACHA, EDAC, is president/CEO of Design At The Intersection LLC and can be reached at firstname.lastname@example.org.