How Are You Using Evidence-Based Design?
Early this year, at the time of the third annual online survey of design research in healthcare settings, the economy was showing signs of a slow recovery. The Architecture Billings Index had been more positive, but architecture firms were expecting revenue gains of just more than 1% for the year (Baker, 2011). Both the annual Health Facilities Management/ASHE construction survey and the AIA Consensus Construction Forecast panel were projecting modest gains in the healthcare sector for 2011, but nowhere near the activity seen in 2008 (Baker, 2011; Carpenter & Hoppszallern, 2011).
However, despite a lack of financing and uncertainty surrounding healthcare legislation and associated reimbursement, the need to replace aging infrastructure and upgrade facilities to accommodate new technology and equipment (as well as meet patient expectations) has resulted in an industry sector better off than the commercial or industrial sectors.
With the outlook for an economic recovery still uncertain, there are many questions surrounding the future of healthcare facility projects; however, most of the more than 1,300 respondents to the survey continue to use design research and evidence-based design (EBD) in their projects. This year’s survey respondents represented a preponderance of members of the consulting design team (architects, interior designers, etc.) but also reflected views from those within provider organizations, as well as researchers, vendors, and others. The survey is structured through several topic areas, including: awareness, information sources, acceptance, application of features, and data collection and dissemination.
Highlights of the survey will be shared during the session "3rd Annual Design Research Awareness Survey" being held at HEALTHCARE DESIGN.11 FROM 11:30 a.m. to 12:30 p.m. in Governor's Ballroom A.
Results for Year 3 indicate the surveyed audience is well aware of design research in healthcare settings, with nearly 82% of respondents indicating some or regular use of design research. With an increase in the overall number of respondents, and the rise of responses to design research awareness in both the “know, but haven’t used it to make decisions” and “never heard of it” categories, there are indications the survey is reaching additional newcomers this year. When asked more specifically about EBD, 72% indicated sometimes or regularly using this process.
While fewer than 2% of respondents indicated not knowing about research on how the design features of the built environment can improve healthcare-related outcomes, 3% indicated they are not familiar with the term EBD. This is an additional indication that more respondents for this year may be newer to the healthcare design field. This is not unexpected, as healthcare has suffered less than other industries during the economic downturn, and many have turned to this sector to expand a base of work. However, with no statistically significant change in the awareness of the term EBD, it appears that the term continues to have wide use within the industry.
Gathering strategies and using information sources
The number of significant changes in the category of gathering information reflects the state of the economy between the first and third years of the survey. In Year 2, travel restrictions and budget controls were commonplace. This continued through the survey period for Year 3 and was reflected in another decline in the use of site visits, benchmarking, and conference attendance—all strategies that could incur significant costs. Declines also continued in the use and awareness of online literature databases (often paid subscriptions) and online research summary databases.
This could be a result of a combination of cost (in the case of annual subscriptions) or the investment of staff time to search databases and conduct industry scans for the latest available research. This is in contrast to increases in the use of blogs and webinars (less expensive options) that saw additional increases in Year 3 from Year 2 (through a reduction in “Never” responses). However, with the statistically significant drops recorded in Year 2, it is encouraging to see the results are not in the same rate of decline from Year 2 to Year 3.
As a requirement in most states, the FGI Guidelines for the Design and Construction of Healthcare Facilities continue as a primary resource for information. Vendome Group LLC’s HEALTHCARE DESIGN magazine and annual HEALTHCARE DESIGN Conference were also some of the more commonly used resources for gathering information about healthcare design strategies, but this is not surprising given survey distribution to The Center for Health Design and Vendome Group lists.
Last year’s survey saw a significant decrease in overall conference attendance that was attributed to the weak economic conditions. While this was not reflected in responses about attendance to the annual HEALTHCARE DESIGN Conference, a statistically significant drop was recorded for the American Society for Healthcare Engineering’s Planning, Design & Construction (PDC) Summit in the Year 2 survey. While overall attendance at conferences continued a decline in Year 3, a significant increase was seen in attendance at the annual PDC conference, indicating a recovery for this event.
That was the only statistically significant change between Year 2 and Year 3 in information sources.
However, additional significant changes between Year 1 and Year 3 often continue trends from Year 1 to Year 2. The increase in “Never Heard of It” for sources such as Healthcare Executive Magazine could be attributed to the decline of respondents for the “Provider” category. Other trends from Year 1 to Year 3, however, are less intuitive. The decline in awareness of both Planetree and the Pebble Project could be an indicator of an increasing number of information sources in the marketplace.
As closed communities, these would not share the same widespread use as open-source or publicly available information. InformeDesign, a literature summary database, also saw a decline in awareness, and between the time of the survey and this report has indicated there will be no additional updates to the database due to lack of funding.
With no significant changes in the definitions of EBD between Year 2 and Year 3, the industry seems to have settled into a common understanding of the term. The continued correlation of positive opinions/statements to “Yes” responses is encouraging, especially in changes relating to the importance of the EBD process during a weak economy and the increases in the amount of available information.
However, with respondents continuing to rely on past projects and articles in mainstream media or industry publications, the details of the latest evidence may be a secondary consideration to many.
Additionally, as EBD gains more traction through the availability of information or industry acceptance, there is an interesting correlation to other opinions. For example, while not a statistically significant change, there has been a decline each year in EBD being seen as a “forward-thinking trend,” as well as a decline in the perception that EBD is a “competitive advantage for an organization.” These could both be indicative that EBD is se
en as more of “the norm,” rather than a novel way of thinking about a healthcare facility project. The danger in this perception of it as a norm is that fewer questions may be asked and many assumptions made. This may be why the opinion that EBD is “something people say they do, but really don’t” remains steadfastly in the middle of “Yes” and “No” responses.
Application of EBD features
In Year 3, the data for use of specific features in single and multiple projects was reviewed separately, and it is notable that there are some statistically significant differences in the responses between these categories. For those working on multiple projects, both the general and inpatient features used most often address safety—the use of gel dispensers, surfaces to reduce contamination or falls, handwashing sinks, and segregation of airflow.
While these are also often used for respondents working on a single project, there appears to be an increased focus on the patient and staff experience, as well. This includes features such as art, gardens, staff support, spaces with light, noiseless paging, large windows with views, building orientation to maximize sunlight, decentralized nursing and supplies, acuity-adaptable rooms, and patient lifts. The shift in focus could be a result of bandwidth—an ability to focus on more details of the project when only considering one facility and/or an issue of project scale.
For those working on multiple projects, the top general EBD features “Always” being incorporated into healthcare facilities are a healing environment that is nurturing, therapeutic, and reduces stress; finishes to reduce contamination; and alcohol-based hand-rub (gel) dispensers. These features are somewhat different for those working on a single project (or a single project with several enabling projects), with the top responses for “Being Implemented” including a healing environment that is nurturing, therapeutic, and reduces stress; alcohol-based hand-rub (gel) dispensers; an integrated wayfinding system; and furniture arrangements to support social interaction.
With respect to the significant changes, it appears that those working on multiple projects are still using alcohol-based hand-rub (gel) dispensers in the general areas of facilities, albeit not as consistently throughout projects with the decrease in “Always” responses (from 60.4% in Year 2 to 53.9% in Year 3). For those working on single projects, there seems to be more emphasis on hand hygiene, with a decrease in handwashing sinks being cut from the project due to budget issues (from 3.7% in Year 2 to 0% in Year 3). The national focus on this issue for the past number of years may be making this deletion less acceptable.
For both single and multiple projects, the trend seen in Year 2 to cut single-bed patient rooms from the project has been reversed in Year 3—nearly recovering to levels seen in Year 1. For those working on multiple projects, this increased from 52.8% “Always” using private patient rooms in Year 2 to 59.1% in Year 3. For those working on individual projects, 5.3% indicated they had been cut from the project for budget reasons in Year 2, but in Year 3, this dropped to 1.7%.
This may be indicative of both the slowly improving economy, as well as a more thoughtful consideration of long-term outcomes and costs, rather than panic-driven reaction to a one-time project budget. However, this could also be a result of projects caught in limbo in the prior year (budgets based on prior economic conditions that could no longer be met) with this year’s respondents reflecting a new set of projects being budgeted within the current market conditions.
Data collection and evaluation
Between Year 2 and Year 3, there were no statistically significant changes in response to the question about conducting formal research. This is a reversal to the statistically significant drop between Year 1 and Year 2, and could be another indicator of a slow and gradual economic recovery. Recognizing that resources may still be constrained, it appears organizations are on a path to maintaining levels of research investment. However, the lack of statistically significant changes in the areas of generating preliminary research, and evaluating and measuring design continues to imply shortcomings in the area of generating and collecting data.
On a positive note, the number of researchers brought on early in the design process (or even during predesign) has increased. In future years, this may have a downstream effect of additional items being generated during design and effectively measured following the design. The use of data reports with specific information to support design decisions and systematic literature reviews both saw modest increases in Year 3, although these increases were not statistically significant from Year 2.
With regard to measuring results, post-occupancy evaluations (POEs) remain the most used tool. However, this is still a lower-rated item for gathering evidence about design strategies in the early phases of a project (the category does show modest increases in use from Year 2). This inconsistency has existed from the first year, and it is unclear why POE findings are not consistently used for the next projects. Several respondents indicated a frustration with the lack of budget to conduct a POE, the desire to “move on,” and the fact that it is always discussed but never happens. Perhaps this inconsistency arises when respondents indicate the use of POEs based on a commitment that does not materialize.
The top perceived barriers to research continue to be funding and time. As reported in the Year 2 results, organizations may be struggling to find new and creative ways to “make ends meet,” and the ability to conduct research may continue to suffer. With the lengthy project lifecycle from planning to research results, there may be a slowing in the annual increases of published studies in the years to come.
Unfortunately, the survey results continue with Year 1 and Year 2 findings that the most used methods of sharing information are internal and not broadly publicized. The most popular ways of disseminating information include project debriefings, staff lunch-and-learns, and hospital leadership meetings. Even these internal methods of sharing information are showing modest declines. This finding may be confounded by the respondent demographic. With a large percentage of the consulting design team responding, and with the design team not always involved in the writing of research articles or dissemination of study results, the findings of the dissemination methods may be skewed.
Overall findings and full report
The results for Year 3 indicate only a few specific areas of statistically significant change between Year 2 and Year 3, with some additional significant changes between Year 1 and Year 3. The most change was seen in how people gather design strategies and their use of specific information resources for healthcare design. This year’s analysis also compared use of features as reported by those undertaking a single project and those working on multiple projects. There are some notable differences in this comparison, with individual projects appearing to include more features that focus on the quality of life for both patients and staff, in addition to the most-used safety features.
EBD continues to be held in a positive regard, in both specific individual opinions and overall industry perceptions. With funding and time in the project schedule still the biggest barriers to conducting research, less rigorous methods of evaluating strategies and measuring results are often used. However, many of the researchers polled indicate they are brought in early in the process, while design decisions
are still being formulated. Unfortunately, dissemination of results continues to be a low point in the process.
A full report of the survey results will be available in late November on The Center for Health Design website at www.healthdesign.org. HCD
Ellen Taylor, AIA, MBA, EDAC, is a Research Associate and Consultant at The Center for Health Design. She can be reached at firstname.lastname@example.org. This project was funded through the generous support of Herman Miller Healthcare. Statistical review of the analysis was provided by Joseph Szmerekovsky, PhD, North Dakota State University College of Business.
Baker, K. (2011, January). The American Institute of Architects - Construction Spending Projected to Turn Up in Second Half of the Year, but Not Enough to Produce an Increase for 2011, Practicing Architecture. American Institute of Architects. Retrieved January 25, 2011, from http://www.aia.org/practicing/AIAB087264
Carpenter, D., & Hoppszallern, S. (2011, February). 2011 Hospital Building Report - Shifting Priorities. Health Facilities Management, 24(2), 13-22.
The Center for Health Design. (2008). Definition of Evidence-Based Design for Healthcare. Retrieved March 24, 2009, from http://www.healthdesign.org/aboutus/mission/EBD_definition.php