An unprecedented $194.5 billion was spent on healthcare construction between 2004 and 2008 (Jones, 2009). However, 2009-2010 marked a new economy. Markets experienced financial losses throughout 2009, and December 2009 marked the second year of revenue declines at U.S. architecture firms (AIA Architectural Billing Index, 2010).

As a result of the worsening economy, some new considerations evolved while developing the 2010 Survey of Design Research in Healthcare Settings: What effect would the economy have on the use of evidence-based design (EBD)? Did people see the economy as a threat or barrier to the process? Were features being removed from projects?

In its second year, the survey was conducted in the first quarter and received more than 1,000 responses, which resulted in a 66% increase in participation from 2009. Yielding both positive and negative results, the survey showed just a few areas of statistically significant change.

Complete survey results are downloadable from The Center for Health Design's Web site at

Respondent demographics

Respondents to the survey included: architects, interior designers, researchers, hospital facility-related staff, healthcare consultants, medical planners, hospital administration (including C-suite and nonfacilities-related leadership), clinicians, and others. Individuals were grouped into broad categories; and while the design team constituted 60% of respondents, nearly 20% of responses were from the provider team.

The Year 2 survey also captured information about the location of projects to determine the international scope of design research. Results indicate that while respondents were primarily engaged in projects in the United States, 21.9% of projects were international (See Figure 1: Project locations of respondent projects and respondent demographics).

Awareness and definitions

Nearly all of those surveyed were aware of research to indicate improved healthcare-related outcomes. More than 83% of respondents stated they “regularly” or “sometimes” used design research to make their decisions (See Figure 2: Awareness of research terminology and definition).

Those participating in design teams were also asked about the awareness of the term “evidence-based design”. Again, a majority of respondents (71%) indicated they sometimes or regularly used EBD (See Figure 2).

Comparing Year 1 and Year 2 of the survey, there was a statistically significant change in the responses regarding awareness of the terminology and a statistically significant change in those who have heard about EBD but don't know much about it. The small but statistically significant shift in awareness may reflect an overall increase in discussions about EBD.

To determine consistency in understanding of the term, the survey posed a question about the best definition of EBD. Nearly two-thirds of respondents chose the definition posited by The Center for Health Design in 2008, “Basing design decisions on credible research to achieve the best possible outcomes.” This was a statistically significant increase from 2009, with a significant decrease noted in those who responded that all of the choices were applicable (See Figure 2).

The changes in the selected definition of EBD seem to reflect a convergence of familiarity and language. With a significant drop in “All of these” responses, it appears that additional people now feel EBD is a more focused and rigorous process for design. This awareness can perhaps be attributed to the Evidence-based Design Accreditation and Certification Program. Instituted after the first year of the survey, this program has created a means to develop a common understanding of the process of EBD.

Location of respondent projects and respondent demographics

The most significant changes were reflected in how information is gathered. Looking at past projects and using Internet searches were the top two methods of gathering information that respondents said they always use. Although the order switched in Year 2 of the survey, the changes were not statistically significant. Despite increased use of Webinars and blogs, respondent use of these methods to learn about healthcare design strategies is still low (See Figure 3: Methods and resources used for healthcare design strategies).

Significant changes, however, included more respondents who never:

Conduct site visits;

Benchmark for best practices; or Use research summary databases.

Additionally, but indicating more use, fewer respondents never:

Participate in Webinars; or

Read blogs.

Significant changes were also seen from those who always:

Attend conferences; and

Use research summary databases.

The number of changes in this category may reflect the state of the economy in early 2010, which was still rife with travel restrictions and budget controls. Methods such as site visits and benchmarking were more consistently “never” used, while the number of those who “always” use conferences was lower in 2010 than in 2009. This contrast increased in the use of blogs and Webinars, which are less expensive learning options. The significant drop in the use of research summary databases (both saw decreases in “always” responses and increases in “never” responses) is not quite as intuitive, but could be a sign of reduced design team fees or allocated hours for staff resources.


Survey participants were asked about their opinions of EBD, as well as their view of overall industry perceptions. Additional choices were included in Year 2 to incorporate issues of economic conditions and the EBD process. Affirmative responses were highly correlated to positive opinion statements. These included perceiving EBD as a way to improve outcomes, make informed decisions, improve the quality of life in healthcare, and improve safety (See Figure 4: Personal opinions of EBD).

Awareness of research, terminology, and EBD definition

Methods and resources used for healthcare design strategies

Personal opinions of EBD

More than one-third of respondents did not feel EBD was at risk during an economic downturn, and nearly 60% felt it was more important during a weak economy. However, one significant shift noted between Year 1 and Year 2 of the survey was in the perception of “There is not enough information.” There were fewer “Yes” responses to this option and more responses from those who had not thought about it.

Aside from individual opinions, respondents were also asked to gauge industry perceptions about EBD. While few felt overall perception was all or mostly negative, very few felt it was all positive. Nearly half of respondents gravitated toward a “mostly positive” perception.

It is encouraging that some of the new options pertaining to EBD and the economy were met with positive, rather than negative, responses (i.e. more important in a weak economy). However, it remains a concern that more than half of the respondents felt that EBD was something people said they did, but didn't really do.

EBD features always used in healthcare

Applications of EBD features

One of the primary goals of the survey is to determine the extent to which evidence is being incorporated into the design and construction of healthcare facilities by measuring trends over time.

General EBD features most often being incorporated into healthcare facilities include a healing environment that is nurturing, therapeutic, and reduces stress; and that has alcohol-based hand-rub (gel) dispensers, and surfaces and finishes to reduce contamination. The most common EBD features specific to inpatient units included: highly visible handwash sink locations, alcohol-based hand-rub (gel) dispensers, segregation of airflow direction, surfaces and finishes to reduce falls, private (single-bed) patient rooms, and patient rooms with designated zones for patients, families, and clinicians (See Figure 5: EBD features always used in healthcare).

Significant changes were recorded in the use of alcohol-based hand-rub(gel) dispensers for both general features and inpatient unit environments features. This change is aligned with increased administrative and public awareness of hand hygiene in healthcare due to the national media attention it's received. However, the trend may also correlate to the weakened economy, which has caused gel dispensers to be used in lieu of more expensive handwashing sink options, especially in renovation projects.

In the “Always” category, statistically significant downward shifts included the use of private patient rooms, but other categories saw decreases in the use of acuity-adaptable rooms and wide or double doors into patient bathrooms. These may all reflect the budget cuts experienced by many organizations throughout the financial crisis. The first-time costs associated with these features can often be so isolated in a capital budget that they can preclude the savings offered through long-term operational costs.

The wide swing in changes in the use of segregated airflow between the Year 1 and Year 2 surveys is most likely due to the rewording and clarification of the survey statement. This is primarily evidenced by the sharp downturn in “Not sure” responses to varying levels of increased use in other categories.

Data collection and evaluation

Of those participating in the planning and design of a healthcare facility, 61% indicated their organization conducted formal research to assess the relevance of design strategies for a particular project. Respondents were questioned whether they generated specific preliminary research items during the design and planning of a project. The results show that many respondents always form a hypothesis about how a design feature may improve an outcome, while some always set measurable goals. Fewer respondents consistently create data reports to inform a design decision, develop specific performance measures to quantify the results of design decisions, or create literature reviews about existing research.

When asked about the types of methods used to evaluate design strategies during planning and design processes, the responses indicated that nearly everyone reviews past projects, tours and benchmarks other facilities, and learns about past and current research related to a specific design feature. While the results are somewhat lower than the responses provided in Year 1, the only statistically significant shift was in the review, evaluation, and summary of research into a formal written report (a systematic literature review). Results indicated a decrease from nearly 50% in Year 1 to 43% in Year 2.

After completing a project, the most common method used to measure results continues to be postoccupancy evaluations. However, this still remains a lower-rated item for gathering evidence about design strategies in the early phases of a project. Other frequently used methods to measure results included before-and-after studies and focus groups. Study types with a potential for additional rigor (prospective studies, natural experiments, or randomized control studies) are less common.


A new category of questions was included in Year 2 pertaining to perceived barriers to design research. Funding and time in the project schedule were indicated as the top detractors to conducting research. More than one-third felt funding was usually the biggest problem (See Figure 6: Perceived barriers to design research).

With the top barriers to research including funding and time, speculation that the economy has had an adverse impact on EBD may be true. As organizations struggle to find new and creative ways to make ends meet, the capacity to conduct new research may continue to suffer through the near future. Because of the time to complete the planning and design of projects, and measure results, there could be a long-term implication in the availability of new published studies beyond the next few years.

Data dissemination

According to the survey results, research findings are most often shared internally. Consistent with last year's results, and reflecting no significant changes, the most used methods are project debriefing, hospital leadership meetings, and internal staff “lunch-and-learn” sessions. The least-used dissemination methods remained constant in Year 2 from Year 1, including Webinars, industry association events (such as an American Institute of Architects-sponsored event), peer-reviewed journals, and interviews with local media (See Figure 28: Disseminating findings). There were no significant changes between Year 1 and Year 2.

Unfortunately, the survey results mirror last year's finding that the most-used methods of sharing information are internal and not broadly publicized. Conference presentations were the fifth most-used method of sharing information-less used than award submissions.

Moving ahead?

When the survey was conducted early this year, the economy was still posting declines, but at a slightly slower pace than in 2009. Unfortunately, while respondents may perceive that EBD is more important during a weak economy and not at-risk during an economic downturn, other categories of questions and responses may imply otherwise. Possible effects of the economy may be manifest in the reduction of:

  • Site visits;

  • Benchmarking;

  • Data reports;

  • Literature reviews; and

  • EBD design features (private rooms, acuity-adaptable rooms, and wide or double bathroom doors in patient rooms).

On the positive, side there is:

  • A slight increase in awareness of the term “evidence-based design”;

  • More clarity in an accepted definition of EBD;

  • Improved perceptions of available information;

  • An increased use of online resources; and

  • An increased use of gel dispensers.

Perceived barriers to design research

In addition, there are few perceived barriers to the process, language, and outcome results of research, and few significant changes to suggest EBD is losing ground in one of the worst economies in recent history.

This project was funded through the generous support of Herman Miller Healthcare. Review of statistical analysis was provided by Joseph Szmerekovsky, PhD. Healthcare Design 2010 November;10(11):88-98