Designed to perform: Exploring the relationship between research, design, and building performance in healthcare

May 1, 2010
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We shape our buildings, and afterwards, our buildings shape us.” (Churchill, 1943). This is a concept that has existed for centuries, yet to this day many healthcare executives are still realizing the shortcomings of the built environment after the building is in use. Even more common is a disconnect between the built environment and its effects on performance outcomes for individuals, the building itself, and the organization. Within the field of Architecture, there remains some disconnect between applying research to design. Fortunately, we are seeing a small but important increase in the number of healthcare design firms employing research professionals, however there is momentum to be gained.

Prior to joining the Pebble Project, the Government of Alberta, Canada, (GoA) was interested in quantifying building performance. Combining principles of evidence-based design (EBD) and the balanced scorecard, the team developed a methodology that can be used to drive and measure the return on investment for all new and recently renovated healthcare facilities. As a member of the Pebble Project research initiative, Alberta Infrastructure is using this newly developed system to evaluate the effectiveness of recent projects in several areas and will use the findings to contribute to “the business case” of healthcare design.

The Pebble Project creates a ripple effect in the healthcare community by providing researched and documented examples of healthcare facilities where design has made a difference in the quality of care and financial performance of the institution. Launched in 2000, the Pebble Project is a joint research effort between The Center for Health Design and selected healthcare providers that has grown from one provider to more than 45. For a complete prospectus and application, contact Mark Goodman at

The issue

In the hospital environment, lives are at stake and both patients and employees can lose not only aspects of their quality of life but their life as a result of design decisions that increase the likelihood of adverse events occurring such as hospital-acquired infections, patient falls, workplace injuries, and workplace errors. In this context, and as stated by Becker (2005), the public expects that hospital facilities and the teams responsible for designing them, draw on the best available research and evidence to assist them in making the most informed design decisions possible. At the organizational level, in an era of fiscal constraint and significant imbalance between supply and demand, there is a need-particularly within the public sector-for healthcare organizations to demonstrate greater accountability for their buildings, for their people, and measure their return on investment.

Research-driven design

Similar to the concepts of evidence-based teaching, evidence-based management, evidence-based medicine, and evidence-based nursing-EBD is the deliberate attempt to find the most up-to-date and rigorous empirical research available to drive design decision making. It refers to a process for designing and creating healthcare environments, based on a theoretical framework and empirical studies, with the goal to improve outcomes in healthcare and monitor the success of designs for subsequent decision making (Ulrich & Zimring 2004).

EBD is not only a process, but a collaboration and mindset. The collaboration draws from the quantified knowledge and expertise of many people with different experience, skills, and perspectives. “It is a mindset that acknowledges that more information, including that generated through formally structured research processes, has the potential to generate plans and buildings that work synergistically on multiple levels: financially, operationally, aesthetically, and in a sustainable manner over time in the face of constant change.” (Becker, 2005) It is also a process that starts with having a project vision and then quantifying that vision into a set of design objectives, questions, propositions, measures, and means for evaluation. The goal of EBD is to acquire the most relevant and scholarly knowledge available that informs, supports, and enhances design decision making, and then to quantify the impact of decisions made.

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