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 mgoodman@healthdesign.org.

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.

The initiative: The building performance evaluation (BPE) scorecard

A recent initiative by the GoA, involved developing a systematic approach for bridging the gap between research, design, and the evaluation of capital projects in healthcare. Working with its architectural and healthcare planning consultant, Cohos Evamy integratedesign, GoA developed a conceptual model and methodology for measuring building performance called the Building Performance Evaluation (BPE) Scorecard. The BPE Scorecard is based on the well-established business sector framework known as the Balanced Scorecard (Kaplan & Norton, 1996), which is a strategic performance management and measurement tool. The design of a Balanced Scorecard is ultimately about identifying a small number of financial and non-financial performance measures and attaching targets to them, so that when they are reviewed it is possible to determine whether current performance meets expectations. As a result, the Scorecard will assist managers to better track areas where performance excels but also where it falls short. They can be encouraged to focus their attention on these areas and trigger improved performance where needed.

Selected strategies and measures are distributed across four performance dimensions, helping to “connect the dots” and forming a visual presentation of building design strategy and measures of performance.

The four Scorecard performance dimensions recognize an integral relationship between:

  • the design of the physical building and life cycle performance (Physical Performance);

  • operational factors and the fiscal bottom-line (Financial Performance);

  • patient outcomes such as length of stay and satisfaction with the healthcare experience (Service Performance); and

  • employee outcomes such as satisfaction with the workplace, absenteeism, recruitment, and retention rates (Functional Performance).

Whereas traditional building evaluations often focus solely on one dimension, the BPE Scorecard provides a more holistic view of building performance by exploring buildings and related attributes from multiple dimensions with the goal to create excellence in design (figure 1).

The instrument: Bridging research to design and performance

Two key components make up the BPE Scorecard methodology. The first component is the conceptual model as shown in figure 1. By addressing the questions asked at the beginning of a design project, the responses will guide building design and the creation of the Scorecard from conceptualization through to lessons learned.

The second fundamental component is the actual Scorecard (figure 2)-a measurement and management tool that bridges research to design and performance. It demonstrates the realtionships between the strategic objectives and design initiatives set for a building at the beginning of a project, and the performance measurement of the outcomes. The Scorecard allows stakeholders to keep an eye on the performance of their buildings from multiple lenses.

In the example provided, rather than assessing an entire hospital or inpatient unit, the BPE project team healthcare organization was interested in assessing the impact of designing a green roof in proximity to an inpatient unit. The green roof was assessed in light of the four performance dimensions. The Scorecard illustrates the process from identifying the objectives for the project through to defining the research propositions, performance measures/ indicators and methods for evaluation. Although not shown here, a second Scorecard was also produced that provided the results of the evaluation in terms of:

  • baseline data on green roofs as acquired from the literature;

  • the results from the pre-occupancy (i.e. pre-move) evaluation; and

  • the postoccupancy (i.e., post-move) evaluation.

This provided invaluable comparative data relative to performance and impact of the green roof.

The uniqueness of the methodology is that it is driven by research at every phase of building delivery, ranging from strategic planning through to immediate and long-term occupancy. Whether research is conducted at the beginning of a design project and/or research involving the evaluation of an occupied unit (e.g. pre- or postoccupancy evaluation), the BPE is a continuous process of systematically evaluating the performance and/or effectiveness of buildings and their attributes. It can assist stakeholders to better understand the effect of early design decisions and to feed forward lessons learned into future design initiatives, ultimately creating better design solutions.

The Alberta government is currently pilot testing the methodology on a large scale tertiary hospital in Alberta. As part of the Pebble Project, the government will evaluate effects of several design interventions and their contribution to improved staff work environments and improved care environments for patients and families. Pre-occupancy data was collected in the fall of 2009, and post-occupancy data will be collect in the fall of 2010. HD

An expanded version of this article was previously published in the Winter 2010 edition of HERD Journal as “Evaluating Building Performance in Healthcare Facilities: An Organizational Perspective.” For more information, visithttp://www.herd journal.com.

Claudia Steinke is Research Lead at Cohos Evamy integratedesign. Lynn Webster is a Health Care Planning and Design Team Leader with Canadian architectural, engineering, and urban planning firm Cohos Evamy integratedesign. Marie Fontaine is an architect and Health Care Facility Specialist with Alberta Infrastructure in Calgary, Alberta, Canada.


  1. Becker F. (2005). Closing the research design gap. Implications: A Newsletter by InformeDesign, 5 (10), 1-5.Retrieved from http://www.informedeisng.umn.edu on February 15, 2010.
  2. Churchill W. ,(1943) Speech to the House of Commons at a meeting in the House of Lords, 28 October 1943.
  3. Kaplan R & Norton D. ,(1996). Translating Strategy into Action: The Balanced Scorecard, Boston, MA:Harvard Business School Press.
  4. Ulrich R., & Zimring C. (2004). The Role of the Physical Environment in the Hospital of the 21st Century: A Once in a Lifetime Opportunity. Report for the Center for Health Design. Robert Wood Johnson foundation.

Healthcare Design 2010 May;10(5):22-29