In 1984, Roger S. Ulrich launched a thousand think pieces, papers, and research projects with the publication of his seminal work on evidence-based design (EBD), “View Through a Window May Influence Recovery from Surgery.” Thirty years later, he’s still the most widely cited researcher in the field. Ulrich left the U.S. four years ago and now lives in Sweden, where he continues his research endeavors and serves as guest professor of architecture for the Centre for Healthcare Architecture at Chalmers University of Technology. As the Center for Health Design bestows its Changemaker Award upon Ulrich at this year’s Healthcare Design Expo & Conference, Healthcare Design spoke with him about the evolution of EBD and what excites him about its future.

Healthcare Design: What’s your take on the state of the evidence-based design (EBD) movement today?

Roger Ulrich: Five years ago, in another interview for Healthcare Design, I noted that the research in this area had progressed a lot. And in the five years since then, the progress has continued, no question. I’m encouraged today by both the increase in quantity and especially the quality of EBD studies.

Going back to 2008, when I last led a literature survey, more than 90 percent of the good research was in medical journals. One had to look widely to find it in different branches of medicine and nursing. Now there’s HERD: Health Environments Research & Design Journal focusing on EBD, and I think that’s helped stimulate research and give more focus to the field. And university design programs today are hiring EBD researchers and designers at the graduate level to supervise masters and PhD students. This is an energetic, growing, alive field.

Has it gone far enough? Of course not. I certainly hope not. As EBD grows as a field, its boundaries—like those of medicine—are expanding. And so there continue to be new issues emerging. There's no end in sight, and this bodes well for the future. As new research findings appear, inevitably it’s the nature of research to reveal new questions and directions for more research. Some findings will be supported or confirmed by other researchers, while other findings will not hold up and therefore be discarded. That's very healthy; it’s how research in any field evolves and grows and improves.

There are certainly several issues relating to healthcare design that have been around for many years yet still lack quality research. But on some issues considerable knowledge has become available. And we're also seeing better theory coming forward, which is important because good theory raises new research questions and can point to new possibilities for design solutions. But if this is to be useful to designers, they need to take the time to understand some of the findings and then think critically and creatively about the implications for design.

Can you give an example of some of the new issues being investigated?

There are several. One good example, and this has been a game-changer internationally, is highlighted by a study done here in Sweden where Karolinska University Hospital renovated a wing in a 1970s building that houses high-acuity NICU babies. The clinicians in the department had for years tried to implement a family-centered care model but were prevented by the fact that the old NICU had open bays with multiple incubators. About seven years ago the department was renovated to become a single-family design layout, where even Level 3 babies (who are very premature and vulnerable, 24-28 weeks gestation), could be with their moms within about four hours after C-section. Instead of mom being assigned a bed in a different unit, mom and dad are now with the baby continuously in a private room in the renovated unit. Even a 25-week baby can be on their mother’s chest for skin-to-skin contact and bonding soon after delivery. Importantly, the clinicians developed and implemented an integrated bundle of family-centered care interventions and components. The architectural renovation is what made implementing the new care model possible.

What made this project a game-changer is that the researchers randomly assigned half of about 360 preterm infants to the new unit, and the other half to the old-style unit that limited the presence of the mom and dad and the amount of training and information they could be given. The new unit cut length of stay in Level 3 intensive care by more than 10 days, and reduced mortality. Several other clinical outcomes were also improved: Infants got to healthier weights faster, and the families were better informed and coped better.

So this is a well-documented example where a carefully specified and integrated cluster of architectural and care process changes substantially improved outcomes.

Obviously, when design can enable major improvements in outcomes in one of the more expensive per-day contexts in healthcare, a lot of money can be saved quickly. As shown in a recent article [Shepley et al., 2014, Journal of Perinatology] the business case that goes with this NICU renovation is powerful.

Some people in the industry, however, have voiced frustration regarding EBD, suggesting that there’s nothing significant happening right now.

Why isn’t there more awareness of EBD research, or the progress I’ve been referring to? I've heard this comment a couple of times myself in northern Europe over the past year. When you hear it from informed people or practitioners, it’s worth stopping and thinking about why they have that view.

I think, frankly, part of the explanation goes back to a critique that many university-based design researchers and teachers have made over the years, that architects and designers generally don’t read much research. Perhaps some healthcare design practitioners do more profession-related reading than average, and there’s a lot for them to read—trends in healthcare, management journals—a lot of diverse information is out there. Not reading research is understandable up to a point; it takes time. The great majority of original research articles appear in scientific or medical journals. The language is technical, descriptions of research methods are complex and scientific... it can be hard slogging.

Nonetheless, I’m disappointed when I see design articles or presentations that simply restate or recycle lists of EBD guidelines from earlier literature reviews. The last comprehensive literature review was in 2008. 

For design practitioners who are busy, who aren't trained in research, it would certainly be desirable to have a way to bring them up to speed more quickly, and put them more in touch with new stuff that's appearing. EDAC [The Center for Health Design’s evidence-based design accreditation and certification program] is one important way of doing this. But there's clearly a need for a new comprehensive review of the literature.

The Center for Heath Design’s website summarizes individual research articles as abstracts and sometimes discusses the design implications. That’s important, and the abstracts are useful. A good systematic review, though, goes beyond that. A new comprehensive review could survey hundreds of studies, including many that have appeared since the last review. And when a skilled, talented team carefully does a systematic review, it can identify patterns across findings and draw broader conclusions. This can enable new insights and sometimes identify new design approaches. A review would also show where there are major gaps in knowledge. A good review also evaluates the strengths, or the scientific quality, of individual studies—so the reader can kn
ow which studies and findings to take more seriously. Right now, that's rarely done.

What will it take for that to happen?

It would take a sizable grant and a team of well-qualified and dedicated researchers. It's a big, sprawling, fast-evolving topic—and it needs a team. I think some of the newer studies are like rough diamonds that are widely scattered through different fields. It takes a team to go out and find them.

Here's a small example that illustrates why a new literature review is needed: There was a study in 2011 called “Infection Acquisition Following Intensive Care Unit Room Privatization” (by Teltsch et al.) that appeared in Archives of Internal Medicine. This journal is selective, influential, quoted by major media, and has a higher readership impact than any design-related journal in the world. This study was no rough gem hidden away in an obscure journal. It was a glittering nugget right there in plain sight.

The research took place at a university medical center in Canada, where rates of different types of drug-resistant infections were studied in two ICUs with multibed rooms. Some rooms held up to 12 patients. One ICU was closed and renovated to single rooms, while the other ICU continued unchanged with multibed rooms.

The researchers compared infection acquisition in the two ICUs. Infection rates continued to be high in the ICU that was not renovated. But importantly, infection rates immediately plummeted in the newly renovated ICU with single rooms. By how much? Acquisition of serious infections (C. difficile, MRSA) went down 54 percent soon after the renovated unit opened. In fact, infections declined so much that the overall length of stay (all patients) in the renovated ICU was shortened by 10 percent. This suggests the renovation saved a lot of money in care costs (not to mention saving lives), and the renovation expense was repaid fairly quickly by cost savings. 

Unfortunately, I detected little or no awareness at conferences or among practitioners of this ICU study, or for that matter of several other design/safety studies that have appeared since the comprehensive literature review in 2008. I have attended healthcare design presentations where architects, facility managers, and even some clinicians recite the same EBD guidelines from the 2008 survey, and then go on to criticize what they see as a lack of new research. This shows these professionals have not taken the trouble to spend a few afternoons using Google Scholar or other research databases to find new studies. Sometimes one hears this complaint from design firms who in the same breath are emphasizing to clients that they have expertise in EBD. It is disappointing. It makes the firm’s claim of EBD expertise ring hollow, because it shows they’re not really trying to stay current.

What do you say to those who suggest that EBD can actually get in the way of innovation?

I take the issue seriously. Going back to the late 1990s, I heard criticism from some architects in the U.S. that EBD was going to constrain creativity and get in the way of innovation. Creativity would be put in handcuffs by EBD guidelines. Some worried that it would have the effect of marginalizing the role of the architect compared to other stakeholders. A few university-based architects (with little practice experience) equated EBD with the Forces of Darkness.

At the time, I was on the faculty of the College of Architecture at Texas A&M University and met regularly with architects from several firms that were major players in healthcare design. By the early 2000s these leading architects/practitioners were saying that EBD promoted innovation rather than hindered it. One effect of EBD was to raise the quality bar in the design specifications for new projects and possibly increase budgets. They indicated that clients were placing more and more priority on design research and that expertise in EBD was an advantage in winning projects. It was becoming a requirement to bid for a growing number of projects.

Concerning creativity versus guidelines, the premise that design should be performance-oriented is basic to the guidelines’ rationale. The effects of the project design on outcomes should be measured. I endorse a performance-based approach to EBD guidelines that leaves it to the design team to find a creative and effective way to build the solution. This certainly should not be a checkbox-based approach to design. Research findings can help designers find new solutions that perform well, and point them away from directions that are likely to fail.

There are many examples of design innovations that arguably never would have occurred if the designers had not been informed by research and performance thinking. Here’s one example that has turned out to be influential. A few years ago I was a consultant to RTKL for a consortium bid for a PFI [private finance initiative] hospital in England. The specifications required single patient rooms with several EBD features and capabilities, but the rooms had to be small (less than 180 square feet).

I suggested to the architects that they annotate the early room designs to show explicit lines of reasoning concerning why specific design features and floor plan aspects would achieve intended consequences, such as reducing infection transmission. In searching for a solution, the architects examined a great variety of conventional rectangular floor plans, and shrank them to the required small size.

They found layouts that performed well if space was in the range of 220-260 square feet—but when shrunk to 170-180 square feet, they imploded and failed, according to EBD criteria. At this point, the design team began to innovate. They experimented with novel shapes and layouts. For each one they thought through whether it would achieve the intended positive effects on patient safety and other outcomes.

This led to what I consider a creative epiphany and breakthrough: a canted, or slanted, patient room—to my knowledge, the first of its kind. Performance analysis (including using mock-ups) showed that the small canted room (177 square feet) was superior to small box shapes across a range of EBD performance criteria. Tony Burley (then with RTKL) and I gave a presentation about the canted room at the 2007 Healthcare Design Conference. Subsequently, canted patient rooms have appeared in new hospitals in Europe and North America.

There are still some architects, unfortunately, who have not learned that EBD doesn’t tell you what to do in each situation. It rarely does. There’s almost no study available that will be directly relevant to the specific problem that a design team is facing. And the job of the design team is to try to understand the findings, see how credible the evidence is, and internalize the knowledge to the point where it can inform their way of coming up with a design that’s high performance.

Most basically, EBD knowledge helps the design team to be better informed with quality information. What could be more empowering for creativity?