It’s not always easy to pinpoint a beginning, and yet it’s human nature to seek the answer to where things began. Humans are curious creatures: From silly curiosities (which came first, the chicken or the egg?) to cerebral discussions such as the Big Bang Theory, we continue to seek answers to questions of genesis, both big and small.

At The Center for Health Design, our mission is about transforming healthcare environments to create better health outcomes, and we achieve this through design research, education, and advocacy. But the nucleus is always research. Without new insights, it’s challenging to push the boundaries of innovative new design concepts. Without new knowledge, it’s difficult to create educational content with much value or depth. And without either proving or debunking standard practice and common theories that may or may not add value to a healthcare building, it’s impossible to change the codes and standards we use to create them.

The Environmental Design Research Association recently named The Center for Health Design as the recipient of its 2014 Organization Award for Excellence in Environmental Design Research, Application, or Education. The award serves as recognition of progress that’s been made in earning acceptance of evidence-based design, which started me thinking about the journey. What was the origin of the research-based healthcare design industry? When did the evidence-based design movement begin to find its footing?

It likely all began in earnest with a brick wall and Dr. Roger Ulrich. There were many earlier studies and observations linking the built environment to health, starting with Florence Nightingale’s “Environmental Theory,” that led to an infusion of natural light and ventilation in hospital design in the mid-1800s. But to this day, no study has been more referenced and quoted as Ulrich’s 1984 article published in the journal Science,View Through a Window May Influence Recovery from Surgery.”

In this study, Ulrich found that post-surgery gall bladder patients had shorter post-operative stays, needed fewer pain killers, had fewer post-surgical complications, and made fewer negative comments when the views through their hospital window overlooked a grove of trees versus a brick wall.

This landmark study opened the door for the next generation of research professionals to focus on elements of the built environment and isolate their impact on healing, productivity, and safety issues in healthcare environments. Since then, the research-based healthcare design field has continued to grow—slowly at first—and is now starting to see a groundswell as more and more universities offer graduate-level programs in healthcare design that use an evidence-based approach.

In 1998, The Center commissioned the first systematic literature review of studies connecting the built environment to better health outcomes, with 84 relevant studies identified. That same search was commissioned in 2004, and 600 studies were found. In 2008, a review yielded more than 1,200 studies. If we were to do the search again today, I have no doubt that that number would surpass 2,000.

It’s interesting to ask the question, “Where did it all start?” But what’s even more fascinating is to watch the birth of an idea grow into adolescence and to be excited about its potential in adulthood. We have all done so much to move this industry forward using a research-based approach to design. Looking forward 25 more years, I believe we will see extraordinary things.

I leave you with a Florence Nightingale quote from 1860: “People say the effect is only on the mind. It is no such thing. The effect is on the body, too. Little as we know about the way in which we are affected by form, by color, and light, we do know this, that they have an actual physical effect. Variety of form and brilliancy of color in the objects presented to patients are actual means of recovery.”


Debra Levin is president and CEO of The Center for Health Design. She can be reached at