Editorials
Evidence-based design of health care facilities
been driven as much by extra payments as by the threat of new entrants, although separating the effects of these policies is undoubtedly difficult. The experience of primary care in England shows that in applying market principles in health care, the devil is in the detail. If the theoretical benefits of choice and competition are to be realized in practice, then much work has to be done to ensure that commissioners have the skills needed, patients are aware of the choices available to them and can exercise these choices, and there is a ‘level playing field’ between providers. Advocates of the use of choice and competition need to descend from the level of argument and theory and be prepared to get their hands dirty in working out what a properly designed market would look like. Chris Ham Professor of Health Policy and Management Email:
[email protected] Jo Ellins Research Fellow
Helen Parker Co-Director Health Services Management Centre 40 Edgbaston Park Road Birmingham B15 2RT, UK DOI: 10.1258/jhsrp.2009.009048
References 1 Le Grand J. Knights, knaves or pawns: human behaviour and social policy. J Soc Policy 1997;26:149 – 69 2 Le Grand J. Motivation, Agency and Public Policy. Oxford: Oxford University Press, 2003 3 Le Grand. The Other Invisible Hand. Princeton, NJ: Princeton University Press, 2007 4 Ellins J, Ham C, Parker H. Choice and Competition in Primary Care: Much Ado About Nothing? Birmingham: Health Services Management Centre, University of Birmingham, 2008 5 National Audit Office. The Provision of Out-of-Hours Care in England. London: The Stationery Office, 2006 6 Picker Institute. National Survey of Local Health Services 2006: Summary Report of Key Findings from the Study. Oxford: Picker Institute, 2007 7 Bate SP, Robert G. Build it and they will come – or will they? Choice, policy paradoxes and NHS Treatment Centres. Pol Polit 2006;34:651 – 72
Evidence-based design of health care facilities The last 15 years have witnessed large investments in health care in the UK. These investments have been made with the aim of improving a system which was considered to be slow, inefficient and below international standards. A wide range of problems were experienced, among them unacceptable levels of health care associated infections and inappropriate work environments. Manifold initiatives were put in place to tackle such problems. Financially, the establishment of public – private partnerships, including the development of ways of procuring new buildings and equipment were introduced, generating much debate. The emergence of new technologies for diagnosis and treatment, and service reconfiguration were other important attempts at improving the quality of care. The principles of ‘lean production’ that had been developed for manufacturing industries were adopted in health care to make processes more efficient and consumer driven. The design of health care environments is complex and challenging. There are many inter-related issues to be addressed including: the variety of users ( patients, visitors, staff ); the frequent technological changes to support diagnosis and treatment; and the nature of the service, which is to care for people’s health and wellbeing when they are most vulnerable. In health care
there is no room for mistakes. Despite many solutions related to infrastructure design having being developed around the world and in spite of the considerable amount of information that is currently available, there is still no certainty regarding what does and does not work. In an attempt to address this, evidence-based design emerged in the 1980s as an approach to support decision-making in design. This approach was adapted from evidence-based medicine which refers to the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.1 In other words, its aim is to apply evidence gained from scientific research to support decisions about the most effective and efficient interventions. Following the same principle, evidence-based design is an approach to assist designers to make decisions based on available knowledge about the impact of those solutions upon people, costs and management.2,3 The built environment, as one of the determinants of health care outcomes, has been depicted in different ways. There are a variety of facilities, care units and settings where research has been conducted. Investigations have focused on the constituent parts of the environment, such as the fabric of the facility (e.g. material and texture),
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Evidence-based design of health care facilities
Editorials
the ambience (e.g. light, noise, temperature, humidity and air), design (e.g. shape, dimensions, layout, colour and art) and the psychological aspects that are related to those (e.g. way-finding, safety and accessibility).4 Although causality cannot be demonstrated, there is a correlation between the built environment and positive and/or negative health outcomes. Many aspects of health care have been investigated including the environment of patients with Alzheimer’s disease5 – 7 and older people8 and measures of patients’ health such as stress,9,10 depression11 and healing times12 and patients’ experiences.13 Considering the vast amount of evidence available, there are two potential benefits of adopting the evidence-based approach. Evidence may challenge old standards and promote innovation based on a solid foundation. The approach can stimulate learning by creating a routine of collecting evidence to investigate whether the right decisions were made and the expected results were achieved. In the USA, Roger Ulrich and colleagues14 presented a review of evidence linking health care environments to impacts on its users. In the UK, the NHS Health Building Notes and Health Technical Memoranda, which started in the 1960s, are based upon evidence. More recent works in the UK include tools created to support the development and assessment of the design of health care facilities. However, despite all the contributions that have been made, several issues regarding the adoption of evidence-based design remain.4 First, from a scientific point of view, there is no consensus regarding theory. Several theories exist to explain the same phenomenon and, as a result, studies have been developed with different theoretical assumptions. Moreover, causal relationships are not clear as there are too many inter-connected variables. Related to this, the variety of research methods that have been used and the quality of the evidence also vary. Second, from a practical point of view, there is a lack of transparency regarding the existing evidence. For example, the level of detail in reports varies. Basic information such as user profile, baseline data, the conditions in which the study was conducted and details related to the environment investigated is often missing in publications. In addition, the knowledge base is fragmented, with hundreds of peer-reviewed journals reporting evidence linking the built environment to impacts on their users. Finally, from a decision-maker’s point of view, there are no guidelines as to how to incorporate evidence in design. Although there is information available to support the conduct of systematic reviews to compile evidence, it does not mean that this information is useful in operationalizing the approach and defining roles and responsibilities in building projects. One consequence is that people can use evidence incorrectly to
justify their decisions. In addition, how best to inform decision-makers about evidence remains a challenge. The process of designing a health care facility involves making thousands of decisions and solving complex trade-offs. How the decision-maker is expected to use evidence in this context is unclear. This is neither a case of preaching about nor condemning evidence-based design. The concept of basing decisions on the best knowledge available is undeniably correct and powerful. A great deal has been learnt about the evidence-based approach in the last decade. Some attempts to deal with the issues mentioned above have been put in place, such as the incorporation of researchers in the design team. However, considerably more could be done to develop this approach. The way forward is clear. In the future greater transparency needs to be brought to the evidence base to make it more accessible and understandable. Additionally, more collaboration between researchers and policy-makers is needed to understand better the contribution of evidence-based design for practice. Ricardo Codinhoto Researcher Ghassan Aouad Pro-Vice Chancellor for Research Mike Kagioglou Head of School Patricia Tzortzopoulos Academic Fellow School of the Built Environment University of Salford Salford M5 4WT, UK Rachel Cooper Director Lancaster Institute for the Contemporary Arts Lancaster University Lancaster, UK DOI: 10.1258/jhsrp.2009.009094
References 1 Sackett DL. Evidence-based medicine. Semin Perinatol 1997; 21:3 – 5 2 Malkin J. A Visual Reference for Evidence-based Design. Concord, CA: The Center for Health Design, 2008 3 Tranfield D, Denyer D, Smart P. Towards a methodology for developing evidence-informed management knowledge by means of systematic review. Br J Manag 2003;14:207 – 22 4 Codinhoto R, Tzortzopoulos P, Kagioglou M, Aouad G, Cooper R. The effects of the built environment on health outcomes. Research Report, HaCIRIC (Health and Care Infrastructure Research and Innovation Centre). 2008. See http://www.haciric.org.
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Editorials 5 Passini R, Pigot H, Rainville C, Tetreault M-H. Wayfinding in a nursing home for advanced dementia of the Alzheimer’s type. Environ Behav 2000;32:684 – 710 6 Zeisel J, Silverstein NM, Hyde J, Levkoff S, Lawton MP, Holmes W. Environmental correlates to behavioral health outcomes in Alzheimer’s special care units. Gerontologist 2003;43:697 – 711 7 Evans GW. The built environment and mental health. J Urban Health 2003;80:536 – 55 8 Ersser S, Wiles A, Taylor H, Wade S, Walsh R, Bentley T. The sleep of older people in hospital and nursing homes. J Clin Nurs 1999;8:360 – 8 9 Bell PA, Green TC. Thermal Stress: Physiological, Comfort, Performance, and Social Effects of Hot and Cold Environments. London: Cambridge University Press, 1982:75 – 104
Evidence-based design of health care facilities 10 Topf M. Hospital noise pollution: an environmental stress model to guide research and clinical interventions. J Adv Nurs 2000;31:520 – 8 11 Kripke DF. Light treatment for nonseasonal depression: speed, efficacy and combined treatment. J Affect Disord 1998;49: 109 – 17 12 Bayo MV, Garcia MA, Garcia A. Noise levels in an urban hospital and workers’ subjective responses. Arch Environ Health 1995;50:247 – 51 13 Douglas CH, Douglas MR. Patient-centred improvements in health-care built environments: perspectives and design indicators. Health Expectations 2005;8:264 – 76 14 Ulrich R, Zimring C, Zhu X, et al. A review of the research literature on evidence-based healthcare design. Health Environments Research & Design Journal 2008;1:61 – 125
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