Working with Herman Miller as a corporate partner, The Center for Health Design has completed the first Survey of Design Research in Healthcare Settings. With more than 600 respondents to the online survey, the results provide insight into questions surrounding the use of research in healthcare design and will set a benchmark for future analysis of industry trends.

While the field of evidence-based design (EBD) field has grown significantly over the last few years, we do not know how much of this knowledge is being translated into the design of new healthcare facilities: How many healthcare projects use an EBD process? Are those planning and designing these facilities coming up with innovative design solutions to address key safety and quality issues in healthcare settings? Are they measuring the impacts of these changes? Is EBD really making a difference?

Those responding to the survey included: architects, interior designers, researchers, hospital-facility-related staff, healthcare consultants, medical planners, hospital administration, and other categories such as vendor/product sales rep, business development/ marketing, construction managers, postgraduate degree candidate (PhD, Masters), and clinicians.


According to a recent construction survey, EBD gained support in 2008, although a large number of hospitals are still not using EBD features (HFM/ASHE 2009 Construction Survey). The same survey indicated that 22% were applying EBD design concepts in all construction projects and 40% for some projects.

In this survey focusing specifically on the use of design research in healthcare, nearly all of those surveyed were aware of design research to indicate improved healthcare-related outcomes. More than 80% of respondents stated they “sometimes” or “regularly” used design research to make their decisions.

Respondents were also asked about the awareness of the term “evidence-based design.” Consistent with the results for awareness of design research, a high percentage of respondents indicated regular use of EBD. However, fewer respondents indicated using EBD “sometimes,” while more indicated hearing about EBD but “not trying to use it yet.”

Information gathering

Respondents were asked about sources used to gather information about design strategies. Some sources “always” used include (figure 1):

Gathering healthcare design strategies

  • internet searches for materials or other projects (43.8%);

  • past projects (38.8%);

  • articles in the mainstream media: news, industry publications (31.7%);

  • site visits to other facilities (29.3%);

  • published research (29%); and

  • peer opinions (27.9%).

Respondents were also asked about resources used most often for information about healthcare design. The top resources “always” used include:

  • The Guidelines for the Design and Construction of Healthcare Facilities (50.7%);

  • HEALTHCARE DESIGN magazine (43.4%);

  • HEALTHCARE DESIGN Conference (24.5%);

  • Health Environments Research & Design (HERD) Journal (18.1%); and

  • CDC Guidelines for Infection Control (17.0%).

Defining evidence-based design

There is often discussion about using the term “evidence-based design”-the availability and credibility of evidence, the use of the term as marketing jargon, and misperceptions about aesthetics versus tangible outcomes. The concerns about EBD are often a result of the term not being well defined, even within healthcare. The Center for Health Design defines EBD as the process of “basing decisions about the built environment on credible research to achieve the best possible outcomes” (The Center for Health Design 2008). As there can sometimes be a casual use of the term, the survey posed a question about the best definition of EBD (figure 2). While the results indicate a familiarity with the formal definition, many also feel that EBD uses a combination of sources and information that may expand the “evidence” base beyond the rigor of what may be deemed credible research.

Defining EBD

Perceptions of EBD

Personal opinions were highly correlated to suggested positive statements about EBD as a way to:

  • improve outcomes (97.9%),

  • make informed decisions (97%);

  • improve the quality of life in healthcare (95.6%); and

  • improve Safety (94.8%).

While respondents were evenly split on whether or not there was enough information available about EBD (46% to 46.3%), most perceptions were positive. Responses to negative statements were correspondingly low: EBD is a waste of money (2%), just a way to meet RFP requirements (6.2%), or a passing fad (8.4%).

Applications of EBD features

The survey was also used to gauge the use of design interventions supported by published research to indicate improved outcomes. Features were broadly categorized into general (i.e., any healthcare setting) or inpatient (more specific to facilities with inpatient units). According to the survey results (figure 3), the top five “general” evidence-based design features always being used in healthcare facilities include:

General EBD features used in healthcare

  • healing environments that are nurturing, therapeutic, and reduce stress (60.0%);

  • Surfaces and finishes to reduce contamination (57.7%);

  • integrated wayfinding: prearrival, maps/guides, signs (50.8%); and

  • alcohol-based hand-rub (gel) dispensers (50.1%).

Respondents indicated always using the following EBD features in inpatient units (figure 4):

Inpatient EBD features used in healthcare

  • private (single-bed) patient rooms (60.4%);

  • highly visible hand wash sinks (57.6%);

  • surfaces and finishes to reduce falls (54.6%);

  • patient rooms with designated areas for patients, families, and clinicians (52.4%);

  • alcohol-based hand-rub (gel) dispensers (47.9%); and

  • large patient room windows with views to nature (47.2%).

Evaluating strategies and measuring results

Two-thirds of respondents indicated their organization conducted formal research to assess the relevance of design strategies for a particular project. In addition, nearly two-thirds of respondents indicate “always” forming a hypothesis about how a design feature may improve an outcome. Fewer respondents, however, create data reports, read literature reviews about existing research, or specific performance measure to quantify the results of design decisions.

The methods used to evaluate design strategies during the planning and design process were consistent with the sources used to gather information about design strategies. The most common responses were:

  • to review past projects (88.2%);

  • tour and benchmark other facilities (86.1%); and

  • learn about research related to a specific design feature (86.1%).

After completing a project, the most common method used to measure design results was a postoccupancy evaluation (71.6%). Interestingly, this was not a frequently used source to gather design strategies. Other frequently used methods used to measure results included before and after studies (46.5%) and focus groups (36.1%). More rigorous study types, such as prospective studies, natural experiments, or randomized control trails, were less common among respondents. Unfortunately, nearly 25% of respondents indicated design results are never formally evaluated after completion.

Sharing results

Survey results indicate the evidence being generated by healthcare providers and their design teams is often not shared, and even less so, outside of the immediate team. The three most common ways information is always shared include:

  • project debriefings (19.8%);

  • internal staff lunch and learns (16.2%); and

  • hospital leadership team meetings (13.3 %).

This is a particular area that warrants focus, as the field can only be improved through habitually disseminating the findings of research, both positive and negative.

Complete survey results

In the first year, the survey sampling audience was primarily limited to readers of HEALTHCARE DESIGN magazine and mailing lists associated with The Center for Health Design. While the results may be skewed due to familiarity with the subject, the first-year results will serve as a benchmark for changes recorded in future surveys. Complete survey results will be presented at HEALTHCARE DESIGN.09 and will be available for download from The Center for Health Design ( in the fall. HD

Healthcare Design 2009 August;9(8):54-65