Innovation in The Frames of Evidence-Based Design Methods: Reflections on The Importance of Communication, Culture, and Context
The focus on the invisible part of evidence-based design (EBD) that almost contradicts the nature of its context made it difficult to write this article. But no visible results are possible without efforts made in terms of methods and process tools. During thousands of meetings for every building project, managers, administrators, designers, architects, healthcare professionals, engineers, and sometimes patients describe, discuss, and decide what will have an enormous impact on patient safety and satisfaction, staff productivity and satisfaction, and quality of care.
“Europe is a chaotic mix of semi-scale socialism or even communism!” say many opponents of the Obama administration's healthcare policies. “If we use inspiration from overseas, it will make our national healthcare even worse,” others claim. And in Scandinavia, we often hear: “Just look at American hospitals-all with limited use of natural daylight, everywhere artificial nature, and multicolored wall-to-wall carpeting as a bad attempt to create a homelike environment! What can we learn from the homeland of evidence-based design?” These stereotype speeches don't actually take into account those who ought to be at the center of constant concern-the patients. Cultural transparency and contextualized communication is totally missing.
Everyone wants to do best
As a former healthcare politician trying to achieve a global meta level of observation, it has been both amusing and provocative to reflect upon the ongoing competition between continents and countries. Almost every healthcare system is aiming to be world-class or even world-leading. It makes so much sense, and yet it doesn't-first, because no one wants to make their healthcare system more dysfunctional and, second, because it may be both an impossible and naïve mission.
Like peace on Earth and worldwide control of all environmental issues, the idea of one healthcare model that fits all must be replaced by a more realistic model based on the agile approach of complex system thinking. Seen through such holistic lenses, the positivistic and linear way of assessing and developing healthcare buildings must be rejected, although that also means saying goodbye to the comfort zone of simplicity and causal effectiveness.
The intention here is to provoke and invite a more cooperative and explorative dialogue between multiple types of global healthcare models and building types. Like the ongoing attempt to find the squaring of the circle, we might never get there. So the best we can do is to applaud the learning and ideas we gain from active and appreciative listening in an open dialogue. We could start by focusing on the hospital as one of the very central typologies in healthcare. And we could narrow our focus even more to observe and discuss the way we build or rebuild these expensive buildings. In addition, processes and methods from EBD can serve as a common shared language and framework from where we can gain in-depth knowledge and inspiration for innovation despite geographical impetus. But if that is going to happen, we must engage more in the creation of shared language and shared methods of understanding.
It is difficult …
Designing and building hospitals often falls under the category of a “mega-project,” during which program management and planning is challenged by a highly explosive mixture of power and politics. Innovation is threatened by the complexity of innovation, cost-analysis, decision-making, etc. But documented case studies are lacking in the field where the EBD process is integrated with the development of a business model. This is a key reason why crosspollination and innovation learned from others is so absent.
What is the value of evidence if you don't know how to use it? The number of projects, articles, and references on EDB worldwide are increasing, but knowledge and insight on how to actually implement EBD in a complex hospital building project are still rare. At a time when so much attention is given to innovation and healing environments, it is disappointing that a deep understanding of this process is missing. Most hospital building projects today claim to embrace the ambition of evidence-based excellence in design and a supporting business model for improved quality and performance. But it is almost impossible to decipher the core methods used to ensure actual integration of EBD principles and knowledge into the building project. Therefore, it is also difficult for many to explain and justify the relationship between the design of the built environment and patient outcomes.
The EBD process in hospitals is dependent on a variety of contexts, including culture, the healthcare system, implementation models, business models, and traditions and paradigms in the building process. A review of the Evidence-Based Design Accreditation and Certification (EDAC) program study guides indicates that they refer to a North American context of health systems and building processes, and that the right answers are not necessarily valid in a European context. The language, methods, and practice of EBD are not yet shared in a global sense and unless they are, a non-innovative-or at best a superficial-environment of change will be maintained. It will take resources and volunteers to make that happen, but it is possible.
Organizational models and models of process seem very much contextualized and vary from project to project and from country to country. That may explain why cross-country and cross-continental learning is lacking. As of today, only 10% of the more than 500 EDAC-accredited professionals are based outside the United States. and only 1.5% are based in Europe. Granted, the program was only launched in 2009, but the ease of staying inside the comfort zone is dominant and, for many reasons, understandable. In the long run, it will deprive the level of innovation in healthcare projects worldwide. We must find ways to transform the creation of shared learning in a global perspective. And that goes for both the United States and Europe.
There are often surprisingly few shared methods and disciplinary tools among design professionals, but common understanding is pivotal to innovation.
… but not impossible!
It's time to stop the theoretical discussions and the “not-invented-here syndrome” and jump to a higher level of debate. The fact is that many patients are harmed due to ignoring the importance of the relationship between the physical environment and what goes on in between the walls. Many patients and families have negative experiences in healthcare buildings. However, they choose to accept and silently adjust to the circumstances as if a hospital stay is something that must be endured and survived-and not to be enjoyed in a healing, meaningful, and comfortable way. Staff, too, struggle with stress, back pain, etc., while delivering high-performance quality care and treatment despite bad design and bad décor, often in addition to extreme bustle in a chaotic organization.
Archimedes said, “Give me a place to stand and a lever long enough, and I can move the world.” In a postdisciplinary world where the old descriptors can be constraining, we need new roles and efficient methods to empower and nourish healthcare design innovation. If we allow it to happen, and hopefully on the platform of EDAC, EBD methods and processes can serve as a kind of system key that can improve the level of crosspollination of concepts and ideas from one healthcare system to another.
The pros and cons to EBD
The topic of EBD is an inviting platform for healthcare professionals, architects, and consultants to voice their opinions. Some say “old wine in new bottles” because we have always done it the EBD way, although we do not write research reports, guidelines, and manuals. Others refuse to use evidence that is still young and to some extent scientifically premature. R
esearch on design and architecture must be done like “real research” with the use of randomized and controlled trials. If not, it can be of no use, others say. And then there are those who, using strict logic, claim that design and architecture are tied to the context and culture in which they are embedded, and therefore it is impossible to use what is considered to be proven evidence from the EBD literature, which is largely U.S.-based. The latter argument is often stated in the local European debate on hospital innovation that springs from the large diversity between national models of healthcare.
Those who claim to embrace EBD often fail when the magnifier of methodology and scientific rigor is set to assess the strength of the conclusions and the possibility for generalizations. Many claim to use EBD as if it is only a matter of putting in a healing garden that can be seen from the bedside of the patient or single-patient rooms, and artwork in the lobby. Often, pre- and post-occupancy data is missing completely, making it impossible to analyze the actual result of any change in design. Finally, many who are supposedly using an EBD process have a total lack of a coherent, multidisciplinary, and transparently described method of design, which makes it difficult to navigate and impossible to assess universal perspectives.
Stop the battle—it kills patients and the business
Neglecting the consequences relating to these issues is damaging on several levels. Irrespective of your position in healthcare as owner, manager, or staff, you are in a business that can either heal or hurt those in your care. You have a responsibility to contribute with a combination of available resources and methods in optimizing the yield for patients. This is the ethical part of the game. It's also pivotal that money be spent on healthcare by taxpayers, national trusts, or insurance companies. It must be invested in a way that attributes the most value in terms of the health and wellbeing of patients. The balance between efficiency and quality must not be “either/or,” but work together in a coherent, sustainable system.
The theory of EBD
Still, many confuse the concepts of EBD and healing architecture. The simple differentiation is that EBD is a method used to achieve healing architecture. But EBD can do more than achieve healing architecture. The focus of EBD is to optimize the value of the desired output. The output can be healing architecture, but it could also be low-energy usage, high efficiency, low staff turnover, or Lean processes. It depends on the specific strategy plan of the business model and the measures chosen to assess its success or performance.
EBD, which is analogous to evidence-based medicine, is rooted in the early research on healing architecture and the psychosomatic reactions to environment and physical space. However, where evidence-based medicine often focuses on the individual patient, the object of EBD research is the complex systems of health and design and how these are related to measurable outcomes. Because of the high level of complexity in healthcare and design, we need to move away from rigid theoretical discussions often focused on qualitative and quantitative research paradigms and accept EBD with a more multidisciplinary approach as, first and foremost, a tool for developing a common and shared language. If we want to increase the global level of healthcare innovation, it is pivotal to increase the focus on how to communicate about EBD.
Communication is the key
Communication means sharing information or a process by which meaning is assigned and conveyed in an attempt to create shared understanding. But speaking about innovation of healthcare systems and hospitals involves many different communication levels, different types of communications, and an awful lot of context and culture. The road from actual patient perception of quality of care to research-based design recommendations is long and tortuous. There are often surprisingly few shared methods and disciplinary tools among design professionals, but common understanding is pivotal to innovation. As important as it is to understand the sociopsychological situation of the patient to be able to increase the effect of treatment and care, it is likewise important to dig into the context to fully understand the influence of the design of the built environment on patient safety and satisfaction. What is the pre- and post-occupancy data? Is it the colors, the size, the view to the gardens outside, or the model of care?
Until now, a lot of communication on hospital design innovation has been through renderings, drawings, and photos. But what you see is often not what you get, especially if a thorough investigation and assessment of the context is not prioritized. This could improve the value of a possible crosspollination from one project to another or from one country to another. To do so, we need to move to a higher level of communication. That will not be easy, but it is necessary if we want the possible global co-creation and innovation of healthcare design to take a more positive direction.
We must move from collective monologue to genuine communication. Collective monologues are more focused on self-promotion. For decades, we have gone on project tours and browsed through magazines without learning as much as we could. Genuine communication requires capability and willpower to actively listen. Principles and tools to practice EBD are an important and relatively simple way to build up this common ground as a solid foundation, but only if we accept that “there are many ways to get to Rome.” Clearly, more voices from outside the United States would participate through the framework of EDAC in the innovative co-creation of global healthcare design if the signal of respectful contextualization came through more clearly and loudly.
A positive side effect of more and better communication is namely the development of relationships. Conflicts in innovative projects are often caused by both conceptual and relational matters, and are often a strong mix of both. It would not be so bad if future changes in healthcare design could embrace these relationships and people started saying, “Just look at American hospitals. I really like the way they visually articulate the patient as a customer. Our public-owned systems could learn a lot!” or, “Let's go to Europe and learn how participant-driven innovation is integrated in complex design development!” Or, it would be even better if they said, “Let's invite a global and multidisciplinary panel of experts to enrich and enlighten our project-and we will let the whole world know what we accomplished together!” That would really catalyze innovation in healthcare design.
Pernille Weiss Terkildsen was trained as a nurse, holds a MSc, Master of Innovation & Leadership, and is PhD fellow at Aalborg University. She is also the owner and CEO of ArchiMed in Copenhagen, Denmark. Healthcare Design 2010 October;10(10):44-49