The evidence-based design (EBD) process outlined in the EDAC (Evidence-Based Design Accreditation and Certification) program can be customized to fit each healthcare environment's unique needs. Despite this flexibility, it can be challenging for healthcare design project teams abroad to apply a process that was originally designed to address the American way of building, and improve issues within the American healthcare system. In other countries that sustain national healthcare system models, the challenges multiply: project design teams must collaborate not just with healthcare owners and operators but with government officials to gain approval for their designs.

Despite the cultural and political differences in the way care is managed and delivered across international borders three EBD pioneers, who were the first EDAC-accredited individuals in their respective countries, are using the EBD process to pave the way for improvement within their own healthcare systems. This article tracks their grassroots educational efforts.


Arthur Brito
Arthur Brito

It was easy for Arthur Brito, director of design at Albert Kahn in Sao Paolo, Brazil, to justify his need to become EDAC accredited. In fact, he credits the EBD process with alleviating some common ambiguities that often cause oversights in healthcare design projects. “There is no such person who fully understands the healthcare environment as to prescribe how its design should be,” says Brito. “Most gaps or mistakes found in a healthcare project are motivated by the lack of information flow and decision-making policy, which EBD methodology helps make clear.”

With offices in the United States, Mexico, and Brazil, the staff of Albert Kahn wholeheartedly embraces the EBD process. They believe in documenting processes and using as much available research as possible to inform their projects. Hospital Israelita Albert Einstein (HIAE) was Albert Kahn's first Brazilian client to formally request research and credible evidence that would inform their design decisions; and their plans to grow EBD awareness and demand did not stop there.

EBD in requests for proposals is still uncommon in Brazil, so Albert Kahn is working with research and education institutes first, to educate them about the importance of EBD. The approach with these institutes is different compared to those within the Brazilian government's healthcare system. The Brazilian Universal Governmental-based health system is supplemented by a private health system of insurers and private providers and has a different agenda than those focused on research and education.

Fortunately for Albert Kahn's staff in Brazil, they are familiar with the government, health system, language, and culture, and have accessibility to guidance from their American colleagues at the two U.S. office locations.


Pernille Weiss Terkildsen
Pernille Weiss Terkildsen

Contrary to the lack of EBD in requests for proposals that Arthur Brito has seen, Pernille Weiss Terkildsen, CEO and founder of ArchiMed in Denmark finds that EBD is a rather common requirement. However, according to Terkildsen, most of those requests for proposals refer to EBD in broad, overarching concepts, which are not measurable to the project. More frequently, it is still seen by many as a fluffy concept-“healing architecture”-not something that can impact outcomes or the bottom line.

Terkildsen explains that another reason that EBD is often disregarded is that Scandinavian hospital architecture has, for many years, been acknowledged around the world as superlative. Because of this prestige, (the Scandinavian market continues to see a large global interest from young architects wanting to work there), the common sentiment has been: “Why bother with EBD? We are already doing OK.”

Terkildsen disputes that view and contends that there is still more to be learned. For her, EBD makes it possible to benchmark without bias, and, maybe most importantly, introduces a core focus on the outcomes of a certain concept or system. She asserts that EBD will enable the design paradigm in her country to finally shift from “We do as we used to do” to “How, why, and because.”

In Denmark, “a challenge is evolving,” Terkildsen says. “There is a need now to explain to the taxpayers and politicians why some hospitals do better than others concerning infection control, rehabilitation, patient satisfaction, staff turnover and more.” Because of this, she believes that EBD will become more apparent and integrated into Scandinavian hospital design in the coming years. “We cannot continue resting on our laurels, and EBD is a great way to build research and knowledge into the built environment.”

And progress has already been evident. Terkildsen compares her experiences in Denmark as a managing nurse and politician, 10-15 years ago when EBD was not an accepted practice in the Danish healthcare system, to today. In the 18 months since she founded ArchiMed, she is already experiencing a profitable business model using EBD, despite the conservatism of the Danish building industry.

In addition to running ArchiMed, Terkildsen is starting a PhD program at Aalborg University that will focus on the EBD process for healthcare. She is pleased that EBD has been standardized by the EDAC program. She even suggests that in time, she aspires to help develop a global adaptation of EDAC: her vision is an archetype where most definitions, models, and tools are alike, but where context-specific tools can also be found to make for easier EBD integration into any hospital project. “EBD as a process tool provides a kind of shared language in a very complex system of hospitals and healthcare systems,” Terkildsen says.

“Shared language and methods are more important than ever in the constant need to innovate healthcare models worldwide. We owe that first to the patients from an ethical point of view,” she says. “Second it will provide a strong foundation of global sustainable innovation for the management of healthcare.”

New Zealand

Like Denmark, New Zealand, has a small healthcare design market that is highly competitive and cost driven. Robert Ansell, principal at AECOM, is actively involved in promoting the EBD process, and shares similar opinions on its benefits with his Danish and Brazilian peers. Since AECOM encourages the use of a process that stresses measured outcomes for patients, their families, and staff that help clients achieve their business objectives, Ansell was already an early adopter of the process that the EDAC program advocates.

Robert Ansell
Robert Ansell

Drawing from his EBD knowledge, Ansell understands that “through research and the application of credible evidence to the project and business case, design interventions can be implemented that will enhance the workplace culture and support a healing and therapeutic environment.” His challenge is the lack of available healthcare design research projects specific to New Zealand healthcare settings.

Each individual's design challenges will vary depending on their current systems, but the goals remain universal: to improve outcomes, patient satisfaction, and the bottom line.

To remedy the deficiency in available credible research, Ansell is currently in discussions with New Zealand's Ministry of Health to obtain funding for the development of a flagship project (a test EBD hospital) that will demonstrate the EBD process in a new healthcare facility. He believes that a practical demonstration setting will provide the most benefit to grow EBD awareness.

Ansell's own interest in EBD has been motivated by a personal drive to reduce nosocomial infections in New Zealand hospitals. The current infection rate stands at 9.5%, and Ansell has been aware for many years that there are measures available in the design of the built environment that will mitigate the spread of environmental infections.

New Zealand's healthcare is controlled largely by the country's government with the private sector having a very small market share. “The New Zealand Government plans to begin a shake-up of the health sector,” Ansell says. “It won't be on the scale of President Obama's initiative, but we hope that the reorganization will assist in creating opportunities for integration of the EBD process.”

Incremental progress

The Center for Health Design, creator of the EDAC program, recognizes the complexities of applying the EBD process outside of the United States. Consequently, as the EDAC program evolves and gains more international interest, how the process could be incorporated into healthcare design projects in other countries will inevitably need to be addressed in both the study materials and the actual examination itself.

Until then, international EDAC-accredited individuals will continue to leverage knowledge and innovation from the United States and within their own countries. Each individual's design challenges will vary depending on their current systems, but the goals remain universal: to improve outcomes, patient satisfaction, and the bottom line. How these goals are realized abroad will be left up to EBD pioneers such as Arthur Brito, Pernille Weiss Terkildsen, and Robert Ansell. HD

To learn more about the EDAC program visit Currently more than 35 countries are represented on the EDAC Interest List and there are 161 accredited individuals.

Healthcare Design 2010 April;10(4):48-51