View source for Evidence-based design

{{short description|Constructing a physical environment based on scientific research}}
{{Evidence-based practices}}

'''Evidence-based design''' ('''EBD''') is the process of constructing a building or physical environment based on scientific research to achieve the best possible outcomes.<ref name=":5">{{Cite web|url=https://www.healthdesign.org/certification-outreach/edac/about|title=EDAC: Evidence-based design accreditation and certification|website=www.healthdesign.org|access-date=2017-11-18}}</ref><ref>{{Cite book|title=Evidence-Based Design for Multiple Building Types|author1=Hamilton, KD|author2=Watkins, DH|publisher=John Wiley & Sons, Inc|year=2009|isbn=978-0-470-12934-0|location=Hoboken, NJ|pages=9}}</ref> Evidence-based design is especially important in [[Medicine:Evidence-based medicine|evidence-based medicine]], where research has shown that environment design can affect patient outcomes. It is also used in architecture, interior design, [[Social:Landscape architecture|landscape architecture]], facilities management, [[Evidence-based education|education]], and [[Engineering:Urban planning|urban planning]]. Evidence-based design is part of the larger movement towards evidence-based practices.

== Background ==
Evidence-based design (EBD) was popularized by the seminal study by Ulrich (1984) that showed the impact of a window view on patient recovery.<ref name=":1">{{Cite journal|last1=Ulrich|first1=Roger S.|last2=Zimring|first2=Craig|last3=Zhu|first3=Xuemei|last4=DuBose|first4=Jennifer|last5=Seo|first5=Hyun-Bo|last6=Choi|first6=Young-Seon|last7=Quan|first7=Xiaobo|last8=Joseph|first8=Anjali|date=2008-01-01|title=A review of the research literature on evidence-based healthcare design|journal=HERD|volume=1|issue=3|pages=61–125|issn=1937-5867|pmid=21161908|doi=10.1177/193758670800100306|citeseerx=10.1.1.1007.6433|s2cid=17170267}}</ref> Studies have since examined the relationships between design of the physical environment of hospitals with outcomes in health, the results of which show how the physical environment can lower the incidence of nosocomial infections, medical errors, patient falls, and staff injuries;<ref>{{Cite journal|vauthors=Leape LL, Brennan TA, et al|date=1991|title=The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II|journal=New England Journal of Medicine|volume=324|issue=6|pages=377–384|doi=10.1056/nejm199102073240605|pmid=1824793|url=https://journalhealthsciences.com/index.php/UDES/article/view/21|doi-access=free}}</ref><ref>{{Cite journal|vauthors=Zhan C, Miller MR|date=2003|title=Excess length of stay, charges, and mortality attribute to medical injuries during hospitalization|journal=Journal of the American Medical Association|volume=290|issue=14|pages=1868–1874|doi=10.1001/jama.290.14.1868|pmid=14532315|doi-access=free}}</ref> and reduce stress of facility users, improve safety and productivity, reduce resource waste, and enhance sustainability.<ref>{{Cite journal|vauthors=Berry LL, et al|date=2004|title=The business case for better buildings|journal=Frontiers of Health Services Management|volume=21|issue=1|pages=3–24|doi=10.1097/01974520-200407000-00002|pmid=15469120|citeseerx=10.1.1.496.6046|s2cid=19432345}}</ref>

''Evidence'' in EBD may include a wide range of sources of knowledge, from [[Systematic review|systematic literature reviews]] to practice guidelines and expert opinions.<ref name=":2">{{Cite journal|last=Stichler|first=Jaynelle F.|date=2010-01-07|title=Weighing the Evidence|journal=HERD|volume=3|issue=4|pages=3–7|issn=1937-5867|doi=10.1177/193758671000300401|pmid=21165847|doi-access=}}</ref> Evidence-based design was first defined as "the deliberate attempt to base design decisions on the best available research evidence" and that "an evidence-based designer, together with an informed client, makes decisions based on the best available information from research and project evaluations".<ref name=":3">{{Cite journal|last=Hamilton|first=Kirk.D.|date=2003|title=The four levels of evidence-based practice|journal=Healthcare Design|volume=3|issue=4|pages=18–26}}</ref> The Center for Heath Design (CHD), a non-profit organization that supports healthcare and design professionals to improve the understanding and application of design that influence the performance of healthcare, patient satisfaction, staff productivity and safety, base their model on the importance of working in partnership with the client and interdisciplinary team to foster understanding of the client, preferences and resources.<ref name=":5"/>

The roots of evidence-based design could go back to 1860 when Florence Nightingale identified fresh air as "the very first canon of nursing," and emphasized the importance of quiet, proper lighting, warmth and clean water. Nightingale applied statistics to nursing, notably with "Diagram of the causes of mortality in the army in the East".<ref name=":4">{{Cite web|url=https://www.royalcollection.org.uk/collection/1075240/notes-on-matters-affecting-the-health-efficiency-and-hospital-administration-of|title=Notes on Matters Affecting the Health, Efficiency and Hospital Administration of the British Army|website=www.royalcollection.org.uk|access-date=2016-05-11}}</ref> This statistical study led to advances in sanitation, although the germ theory of disease was not yet fully accepted.

Nightingale was also an enthusiast for the therapeutic benefits of sunlight and views from windows. She wrote: "Second only to fresh air … I should be inclined to rank light in importance for the sick. Direct sunlight, not only daylight, is necessary for speedy recovery … I mention from experience, as quite perceptible in promoting recovery, the being able to see out of a window, instead of looking against a dead wall; the bright colours of flowers; the being able to read in bed by the light of the window close to the bed-head. It is generally said the effect is upon the mind. Perhaps so, but it is not less so upon the body on that account ...."<ref>(Nightingale,F. (1860) Notes on Nursing, Harrison, London.</ref>

Nightingale’s ideas appear to have been influential on E R Robson, architect to the London School Board, when he wrote: “It is well known that the rays of the sun have a beneficial influence on the air of a room, tending to promote ventilation, and that they are to a young child very much what they are to a flower.” <ref>E R Robson, (1874) School Architecture, John Murray, London.</ref>

The evidence-based design movement began in the 1970s with [[Biography:Archie Cochrane|Archie Cochranes's]] book ''Effectiveness and Efficiency: Random Reflections on Health Services''.{{sfn|Cochrane|1972}} to collect, codify, and disseminate "evidence" gathered in randomised controlled trials relative to the built environment. A 1984 study by Roger Ulrich<ref>{{Cite journal|last=Ulrich|first=R. S.|date=1984-04-27|title=View through a window may influence recovery from surgery|journal=Science|language=en|volume=224|issue=4647|pages=420–21|doi=10.1126/science.6143402|issn=0036-8075|pmid=6143402|bibcode=1984Sci...224..420U|citeseerx=10.1.1.669.8732}}</ref> seemed to support Nightingale's ideas from more than a century before: he found that surgical patients with a view of nature suffered fewer complications, used less pain medication and were discharged sooner than those who looked out on a brick wall; and laid the foundation for what has now become a discipline known as evidence-based design. Studies exist about the psychological effects of lighting, carpeting and noise on critical-care patients, and evidence links physical environment with improvement of patients and staff safety, wellness and satisfaction.<ref name=":1" /> Architectural researchers have studied the impact of hospital layout on staff effectiveness,<ref>{{Cite journal|vauthors=Clipson CW, Johnson RE |date=1987|title=Integrated approaches to facilities planning and assessment|journal=Planning for Higher Education|volume=15|issue=3|pages=12–22}}</ref><ref>{{Cite book|title=Planning for cardiac care: A guide to the planning and design of cardiac care facilities|author1=Clipson, CW  |author2=Wehrer, JJ |name-list-style=amp |publisher=Health Administration Press|year=1973|location=Ann Arbor, MI}}</ref> and social scientists studied guidance and [[Earth:Wayfinding|wayfinding]].<ref>{{Cite book|title=Design that cares: Planning health facilities for patients and visitors, 2nd edition.|vauthors=Carpman J, Grant M |publisher=American Hospital Publishing|year=1993|location=Chicago, IL}}</ref> In the 1960s and 1970s numerous studies were carried out using methods drawn from behavioural psychology to examine both people’s behaviour in relation to buildings and their responses to different designs – see for example the book by David Canter and Terence Lee <ref>Canter, D and Lee, T, (1974) Psychology and the Built Environment, Wiley, New York.</ref> More recently, architectural researchers have conducted post-occupancy evaluations (POE) to provide advice on improving building design and quality.<ref>{{Cite book|title=Building evaluation techniques |editor=Baird, G. |editor2=Gray, J. |editor3=Isaacs, N. |editor4=Kernohan, D. |editor5=McIndoe, G. |publisher=McGraw-Hill|year=1996|location=New York}}</ref><ref>{{Cite book|title=Handbook of environmental psychology|last=Zimring, CM|publisher=Wiley|year=2002|editor1=Bechtel RB |location=New York|pages=306–23|chapter=Postoccupancy evaluation: Issues and implementation}}</ref> While the EBD process is particularly suited to healthcare, it may be also used in other fields for positive health outcomes and provision of healing environments.

While healthcare proved to be one of the most prominent sectors to examine the evidence base for how good design benefits building occupants, visitors and the public, other sectors also have considerable bodies of evidence. And, many sectors benefit from literature reviews that draw together and summarise the evidence. In the UK some were led by the UK Commission for Architecture and the Built Environment, a government watchdog established by the Labour Party following its election in 1997 and commitment to improving the quality of the UK stock of public sector buildings. Other reviews were supported by various public or private organisations, and some were undertaken in academia. Reviews were undertaken at the urban scale, some were cross-sectoral and others were sector based (hospitals, schools, higher education). An academic paper by Sebastian Macmillan <ref>Macmillan, S, (2006) Added Value of Good Design, Building Research and Information, 34 (3) 257-271.</ref>) gives an overview of the field as it was in 2006.

==A cautionary note about the strength of evidence in the built environment==
In supporting evidence-based design, some caution is needed to ascertain the robustness of the evidence: the architectural psychology movement eventually drew criticism for its tendency towards ‘architectural determinism’ – a confusion between correlation and causality with the implication that there were mechanistic and causal links between the built environment and human behaviour. As some of the studies reviewed below reveal, the evidence is often weak or, worse, conflicting. In an early review of evidence in the healthcare sector, Rubin, Owens & Golden<ref>Rubin, H., Owens, A.J. and Golden, G. (1998) Status Report: An Investigation to Determine Whether the Built
Environment Affects Patients’ Medical Outcomes. Center for Health Design, Martinez, CA.</ref> examined the medical literature for research papers on the effect of the physical environment on patient outcomes. They concluded that, if the demanding standards of proof used in medical research were used, almost all the studies would have to be regarded as methodologically flawed or at least limited. Unfortunately strongly held opinions are not the same as rigorously collected evidence.
 
==Evidence-base for architecture generally, housing and urban environments==
In 2002, CABE published a cross-sectoral study <ref>CABE, (2002) The Value of Good Design: how buildings and spaces create economic and social value</ref> that set a pattern by reviewing a selection of the evidence (which it called the key research) for healthcare buildings, educational buildings, housing, urban environments, and business premises. It claimed: “Good design is not just about the aesthetic improvement of our environment, it is as much about improved quality of life, equality of opportunity and economic growth. … Good design does not cost more when measured across the lifetime of the building or place …”

At the urban scale, in 2001, CABE and DETR published a study on the value of urban design <ref>CABE and DETR, (2001) The value of urban design, Thomas Telford, Tonbridge: 2001</ref> which includes a literature review plus some case studies.

In New Zealand, a landmark review <ref>McIndoe, G., Chapman, R., McDonald, C., Holden, G., Howden-Chapman, P. and Sharpin, A. (2005) The Value of Urban Design: The Economic, Environmental and
Social Benefits of Urban Design, Ministry for the Environment, Wellington</ref>
was supported by the Ministry for the Environment. The study categorised the evidence as conclusive, strong, suggestive or anecdotal, and also noted the difficulty of establishing causation since various design elements may be found in combination with other features. The authors state that urban design is context-specific and cautions against automatically adopting what works elsewhere in New Zealand.
 
In its 2003 review of the evidence about housing <ref>CABE, (2003) The value of housing design and layout</ref> CABE expressed similar concerns about the evidence base when it said: “The most striking finding in a review of the literature relating to the quality of residential design is the almost complete absence of any empirical attempts to measure the implications of high quality on costs, prices or values.”

David Halpern’s book <ref>Halpern, D. (1995) Mental Health and the Built Environment: more than bricks and mortar?, Taylor & Francis, London</ref> brings together and reviews a substantial number of studies covering among other issues: mental ill-health in city centres; social isolation in out of town housing estates; residential satisfaction; and estate layouts, semi-private spaces and a sense of community. He concludes that there is substantial evidence to show the physical environment has real and significant effects on group and friendship formation, and on patterns of neighbourly behaviour.

Other literature reviews include a 2006 study by the Scottish Executive <ref>Scottish Executive, (2006) A literature review of the social, economic and environmental impract of architecture and design (by Morris Hargreaves McIntyre) 2006</ref> and one by the UK NWDA/RENEW North West.<ref>NWDA/RENEW North West, The Economic Value of Urban Design, 2007. A supplement was provided in 2009.</ref>

==Public open space==
CABE’s 2004 literature review on public open space<ref>CABE, (2004) The value of public open space</ref> draws attention to the physical and mental health benefits associated with access to recreational space, as well as the environmental value of biodiversity and improved air quality. In a follow up 2005 study entitled Does Money Grown on Trees?<ref>CABE, (2005) Does Money Grow on Trees?</ref> CABE assessed the impact on the value of residential property of proximity to a park, drawing on valuations prepared by local property experts in which external variables (shops, schools, busy roads) were controlled for. Economic and non-monetary benefits from the proximity were identified.
 
==Schools and Higher Education==
A comprehensive review of the literature was undertaken in 2005 for the Design Council.<ref>Higgins, S., Hall, E., Wall, K., Woolner, P., and McCaughey, C. (2005) The Impact of School Environments: a literature review, produced for the Design Council by the University of Newcastle.</ref> It concluded that there was evidence for the effect of basic physical variables (air quality, temperature, noise) on learning but that once minimum standards were achieved, further improvements were less significant. The reviewers found forceful opinions on the effects of lighting and colour but that the supporting evidence was conflicting. It was difficult to draw generalizable conclusions about other physical characteristics, and the interactions between different elements was as important as single elements.
 
Other literature reviews of the education sector include two by Price Waterhouse Coopers <ref>
Price Waterhouse Coopers, (2001) Building Performance: an empirical assessment of the relationship between schools capital investment and pupil performance, Research Report 242, Department for Education and Employment, London.</ref><ref>PricewaterhouseCoopers, (2003) Building better performance: an empirical assessment of the learning and other impacts of schools capital investment, Research Report No 407, Department for Education and Skills, London.</ref> and one by researchers at the University of Salford.<ref>Barrett, P and Zhang, Y. Optimal Learning Spaces: Design Implications for Primary Schools, Salford Centre for Research and Innovation in the built and human environment, 2009.</ref> 
 
In the higher education sector, a review by CABE<ref>CABE, Design for Distinction: the value of good building design in higher education, 2005</ref> reports on the links between building design and the recruitment, retention and performance of staff and students. Fifty articles are reviewed, and five new case studies reported.

==Offices==
The offices sector has been widely studied with the major concerns focusing on productivity. A study in 2000 by Sheffield Hallam University<ref>Haynes, B., Matxdorf, F., Nunnington, N., Ogunmakin, C., Pinder, J. and Price, I., Does property benefit occupiers? An evaluation of the literature, Occupier.org report number 1, Facilities Management Graduate Centre, Sheffield Hallam University, 2000.</ref> reported that apart from surveys of occupants of individual offices, the evidence base on new workplaces was mainly journalistic and biased towards interviews with successes and failures. Some companies claimed that new spatial arrangements led to reduced costs, reduced absenteeism and easier recruitment, faster development of new ideas, and increased profitability. But others reported the exact opposite; and the reasons for this remained unclear.

CABE and the British Council for Offices published a joint study in 2005.<ref>CABE and the BCO, (2005) The impact of office design on business performance.</ref> The paper reports that four main issues have been studied: the largest is environmental and ergonomic issues related to the comfort of individual office workers; secondly research on the efficiency with which office space is used; thirdly adaptability and flexibility and finally research related to supporting work processes. The report is critical of the disproportionate focus on the performance of building services compared with other aspects of buildings.

== Evidence-based design for healthcare facilities ==
There is a growing awareness among healthcare professionals and medical planners for the need to create patient-centered environments that can help patients and family cope with the stress that accompanies illness.<ref name=":8">{{Cite journal|vauthors=Ulrich RS, Simons RF, Losito BD, et al|date=1991|title= Stress recovery during exposure to natural and urban environments|journal=Journal of Environmental Psychology|volume=11|issue=3|pages=201–230|doi=10.1016/s0272-4944(05)80184-7}}</ref> There is also growing supporting research and evidence through various studies that have shown both the influence of well-designed environments on positive patient health outcomes, and poor design on negative effects including longer hospital stays.<ref name=":8"/>

Using [[Biology:Biophilic design|biophilic design]] concepts in interior environments is increasingly argued to have positive impacts on health and well-being through improving direct and indirect experiences of [[Earth:Nature|nature]]. Numerous studies have demonstrated improved patient health outcomes through environmental measures; exposing patients to nature has been shown to produce substantial alleviation of pain, and limited research also suggests that patients experience less pain when exposed to higher levels of daylight in their hospital rooms.<ref>{{Cite journal|vauthors=Malenbaum S, Keefe FJ, Williams AC, Ulrich R, Somers TJ|date=2008|title=Pain in its environmental context: Implications for designing environments to enhance pain control|journal=Pain|volume=134|issue=3|pages=241–244|doi=10.1016/j.pain.2007.12.002|pmid=18178010|pmc=2264925}}</ref> Patients have an increased need for sleep during illness, but suffer from poor sleep when hospitalised.<ref name=":7">{{Cite journal|vauthors=Southwell MT, Wistow G|date=1995|title=Sleep in hospital at night – are patients' needs being met?|journal=Journal of Advanced Nursing|volume=21|issue=6|pages=1101–1109|doi=10.1046/j.1365-2648.1995.21061101.x|pmid=7665774}}</ref> Approaches such as single-bed rooms and reduced noise have been shown to improve patient sleep.<ref name=":7"/> Natural daylight in patient rooms help to maintain circadian rhythms and improve sleep.<ref>{{Cite journal|vauthors=Wakamura T, Tokura H|date=2001|title=Influence of bright light during daytime on sleep parameters in hospitalized elderly patients|journal=Journal of Physiological Anthropology and Applied Human Science|volume=20|issue=6|pages=345–351|doi=10.2114/jpa.20.345|pmid=11840687|doi-access=free}}</ref>

According to Heerwagen,<ref name=":6">{{Cite journal|author=Heerwagen, J.|date=2000|title= Green buildings, organizational success and occupant productivity|journal=Building Research and Information|volume=28|issue=5–6|pages=353–367|doi=10.1080/096132100418500|s2cid=1145350}}</ref> an environmental psychologist, medical models of health integrate behavioral, social, psychological, and mental processes. Contact with nature and daylight<ref>{{Cite book|title=Sustainable commercial interiors|author1=Bonda, P. |author2=Sosnowchik, K.|publisher=John Wiley & Sons|year=2006|isbn=978-0-471-74917-2|location=Hoboken, New Jersey|url-access=registration|url=https://archive.org/details/sustainablecomme0000bond}}</ref> has been found to enhance emotional functioning; drawing on research from studies (EBD) on well-being outcomes and building features. Positive feelings such as calmness increase, while anxiety, anger, or other negative emotions diminish with views of nature.<ref>{{Cite journal|vauthors=Hartig T, et al|date=1995|title= Environmental influences on psychological restoration|journal=Scandinavian Journal of Psychology|volume=23|pages=109–123}}</ref><ref name=":9">{{Cite journal|vauthors=Van den Berg AE, et al|date=2003|title=  Environmental preference and restoration: How are they related? |journal=Scandinavian Journal of Psychology|volume=23|issue=2|pages=135–146|doi=10.1016/s0272-4944(02)00111-1}}</ref> In contrast there is also convincing evidence that stress could be worsened and ineffective in fostering restoration in built environments that lack nature.<ref name=":9"/>

Few studies have shown the restorative effects of gardens for stressed patients, families and staff.<ref name=":10">{{Cite book|title=Healing gardens: Therapeutic benefits and design recommendations|author1=Marcus, CC. |author2=Barnes, M.|publisher=John Wiley & Sons|year=1999|location=Hoboken, New Jersey}}</ref> Behavioural observation and interview methods in post occupancy studies of hospital gardens have shown a faster recovery from stress by nearly all garden users.<ref name=":11">{{Cite book|title=Gardens in healthcare facilities: Uses, therapeutic benefits, and design recommendations|author1=Marcus, CC. |author2=Barnes, M.|publisher=Center for Health Design|year=1995|location=Concord,CA}}</ref> Limited evidence suggest increased benefits when these gardens contain foliage, flowers, water, pleasant nature sounds, such as birds and water.<ref name=":10"/><ref name=":11"/><ref name=":1"/>

== Related approaches ==

=== {{anchor|Performance Based Building Design (PBBD)}}Performance-based building design===
EBD is closely related to [[Engineering:Performance-based building design|performance-based building design]] (PBBD) practices. As an approach to design, PBBD tries to create clear statistical relationships between design decisions and satisfaction levels demonstrated by the building systems. Like EBD, PBBD uses research evidence to predict performance related to design decisions.

The decision-making process is non-linear, since the building environment is a complex system. Choices cannot be based on cause-and-effect predictions; instead, they depend on variable components and mutual relationships. Technical systems, such as heating, ventilation and air-conditioning, have interrelated design choices and related performance requirements (such as energy use, comfort and use cycles) are variable components.

=== {{anchor|Evidence Based Medicine}}Evidence-based medicine===
[[Medicine:Evidence-based medicine|Evidence-based medicine]] (EBM) is a systematic process of evaluating scientific research which is used as the basis for clinical treatment choices.<ref>{{Cite journal|last1=Claridge|first1=Jeffrey A.|last2=Fabian|first2=Timothy C.|date=2005-05-01|title=History and development of evidence-based medicine|journal=World Journal of Surgery|volume=29|issue=5|pages=547–53|doi=10.1007/s00268-005-7910-1|issn=0364-2313|pmid=15827845|s2cid=21457159}}</ref> Sackett, Rosenberg, Gray, Haynes and Richardson argue that "evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients".<ref>{{Cite journal|last1=Sackett|first1=David L.|last2=Rosenberg|first2=William M. C.|last3=Gray|first3=J. A. Muir|last4=Haynes|first4=R. Brian|last5=Richardson|first5=W. Scott|date=1996-01-13|title=Evidence based medicine: what it is and what it isn't|url= |journal=BMJ|language=en|volume=312|issue=7023|pages=71–72|doi=10.1136/bmj.312.7023.71|issn=0959-8138|pmid=8555924|pmc=2349778}}</ref> It is used in the healthcare industry to convince decision-makers to invest the time and money to build better buildings, realizing strategic business advantages as a result. As medicine has become increasingly evidence-based, healthcare design uses EBD to link hospitals' physical environments with healthcare outcomes.

=== {{anchor|Research-Informed Design}}Research-informed design===
Research-informed design (RID) is a less-developed concept that is commonly misunderstood and used synonymously with EBD, although they are different. It can be defined as the process of applying credible research in integration with the project team to inform the environmental design to achieve the project goals. Credible research here, includes qualitative, quantitative, and mixed methods approaches with the highest standards of rigor suitable for their methodology.
It is important to understand that the literature for "research-informed" practices comes from [[Evidence-based education|education]] and not from the healthcare disciplines.<ref>{{Cite journal|last1=Bentley|first1=Y.|last2=Richardson|first2=D.|last3=Duan|first3=Y.|last4=Philpott|first4=E.|last5=Ong|first5=V.|last6=Owen|first6=D.|date=2013|title=Research-informed curriculum design for a master's level program in project management|journal=Journal of Management Education|volume=37|issue=5|pages=651–682|doi= 10.1177/1052562912458642|s2cid=145443323}}</ref> The process involves application of the outcomes from literature review and empirical investigation to inform design during the design phase, given the constraints; and to share the process and the lessons learnt just like in EDB.

== {{anchor|Current state|Research centers|Accreditation and certification}}Research and accreditation==
As EBD is supported by research, many healthcare organizations are adopting its principles with the guidance of evidence-based designers. The Center for Health Design developed the Pebble Project,<ref>{{Cite web | url=https://www.healthdesign.org/research-services/pebble-project | title=Becoming a Pebble Partner &#124; the Center for Health Design| date=20 July 2010}}</ref> a joint research effort by CHD and selected healthcare providers on the effect of building environments on patients and staff. ''Health Environment Research & Design'' journal and the Health Care Advisory Board<ref>{{Cite web | url=https://www.advisory.com/research/health-care-advisory-board | title=Health Care Advisory Board}}</ref> are additional sources of information and database on EBD.

The Evidence Based Design Accreditation and Certification (EDAC) program was introduced in 2009 by The Center for Health Design to provide internationally recognized certification and promote the use of EBD in healthcare building projects, making EBD an accepted and credible approach to improving healthcare outcomes.<ref name=":5" /> EDAC identifies those experienced in EBD and teaches about the research process: identifying, hypothesizing, implementing, gathering and reporting data associated with a healthcare project.

== {{anchor|Evidence-Based Design Process}}Process ==
There are four components to evidence-based design:<ref>{{Cite book|title=Evidence-based healthcare design|last=Cama|first=Rosalyn|publisher=John iley & Sons, Inc|year=2009|isbn=9780470149423|location=Hoboken, NJ}}</ref>
*Gather qualitative and quantitative intelligence
* Map strategic, cultural and research goals
*Hypothesize outcomes, innovate, and implement translational design
* Measure and share outcomes

=== Meta-analysis template for literature review ===
In his book ''Evidence-based Policy: A Realistic Perspective'', Ray Pawson<ref>{{Cite book|title=Evidence-Based Policy: A Realist Perspective|last=Pawson|first=Ray|publisher=Sage|year=2006|isbn=9781412910606}}</ref> suggests a meta-analysis template which may be applied to EBD. With this protocol, the field will be able to provide designers with a source for evidence-based design.

A systematic review process should follow five steps:
# Formulating the review question 
# Identifying and collecting evidence
# Evaluating the quality of the evidence
# Extracting, processing and systematizing data
# Disseminating findings

=== {{anchor|Conceptual model for the application of EBD}}Conceptual model ===
According to Hamilton,<ref name=":3"/> architects have a responsibility in translation of research in the field, and its application in informing designs. He further illustrates a conceptual model architects could use, that identifies four levels of addressing research and methods base on varying levels of commitment: 
* Level 1
** Informed design decisions based on available literature on environmental research, based on applicability, such as the use of a state of the art technology or strategy based on the physical setting of the project
* Level 2
** Design decisions based on predictive performance and measurable outcomes, rather than subjective decisions based on random choice
* Level 3
** Results reported publicly, with the objective of moving information on the methods and results moving information beyond the design team, 
** The peer review, makes the process more robust, as it could include varying perspectives from those who may or may not agree with the findings
* Level 4
** Publishing findings in peer-reviewed journals
** Collaborating with academic and social scientists

=== {{anchor|Working model for the application of EBD}}Working model ===
A white paper (series 3/5) from the Center for Health Design<ref name=":0">{{Cite web|url=http://hcleader.healthdesign.org/HCLeader_3_CEORoleWP.pdf|title=Implementing healthcare excellence: the vital role of the CEO in evidence based design. Healthcare Leadership White Paper Series, 3 of 5.|author1=Zimring, C.M. |author2=Augenbroe, G.L. |author3=Malone, E.B. |author4=Sadler, B.L.|date=September 2008}}</ref> presents a working model to help designers implement EBD decision-making. The primary goal is providing a healing environment; positive outcomes depend on three investments:
* Designed infrastructure, including the built environment and technology
* Re-engineered clinical and administrative practices to maximize infrastructure investment
* Leadership to maximize human and infrastructure investments

All three investments depend on existing research.

=== {{anchor|Ten strategies for the implementation of EBD}}Strategies ===
A white paper from the Center for Health Design identifies ten strategies to aid EBD decision-making:<ref name=":0" />
#Start with problems. Identify the problems the project is trying to solve and for which the facility design plays an important role (for example, adding or upgrading technology, expanding services to meet growing market demand, replacing aging infrastructure)
#Use an integrated multidisciplinary approach with consistent senior involvement, ensuring that everyone with problem-solving tools is included. It is essential to stimulate synergy between different community to maximize efforts, outcomes and interchanges.
#Maintain a patient- and family-centered approach; patient and family experiences are key to defining aims and assessing outcomes.
#Focus on financial operations past the first-cost impact, exploring the cost-effectiveness of design options over time and considering multi-year investment returns.
#Apply disciplined participation and criteria management. These processes use decision-making tools such as [[Social:SWOT analysis|SWOT analysis]], analytic hierarchy processes and [[Decision tree|decision tree]]s which may also be used in design (particularly of technical aspects such as structure, fire safety or energy use).
#Establish incentive-linked criteria to increase design-team motivation and involve end users with checklists, surveys and simulations.
#Use strategic partnerships to create new products with hospital-staff expertise and influence.
#Encourage simulation and testing, assuming the patient's perspective when making lighting and energy models and computer visualizations.
#Use a lifecycle perspective (30–50 years) from planning to product, exploring the lifecycle return on investment of design strategies for safety and workforce outcomes.
#Overcommunicate. Positive outcomes are connected with the involvement of clinical staff and community members with meetings, newsletters, webcams and other tools.

== Tools ==
Evidence-based design has been applied to efficacy measurements of a building's design, and is usually done at the post-construction stage as a part of a post-occupancy evaluation (POE). The POE assesses strengths and weaknesses of design decisions in relation to human behaviour in a built environment. Issues include acoustics, odor control, vibration, lighting and user-friendliness, and are binary-choice (acceptable or unacceptable). Other research techniques, such as observation, photography, checklists, interviews, surveys and focus groups, supplement traditional design-research methods.
Assessment tools have been developed by The Center for Health Design and the Picker Institute to help healthcare managers and designers gather information on consumer needs, assess their satisfaction and measure quality improvements:
* The ''Patient Environmental Checklist'' assesses an existing facility's strong and weak points. Specific environmental features are evaluated by patients and their families on a 5-point scale, and the checklist quickly identifies areas needing improvement.
* The ''Patient Survey'' gathers information on patients' experiences with the built environment. The questions range is wide, since patients' priorities may differ significantly from those of administrators or designers.
* ''Focus Groups'' with consumers learn about specific needs and generate ideas for future solutions.

==References==
{{Reflist}}
* Cama, R., "Patient room advances and controversies: Are you in the evidence-based healthcare design game?", ''Healthcare Design'', March 2009.
* {{cite book |last1=Cochrane |first1=A. L. |title=Effectiveness and Efficiency: Random Reflections on Health Services |date=1972 |publisher=Nuffield Provincial Hospitals Trust |isbn=978-0-900574-17-7}}
* Hall, C.R., "CHD rolls out evidence-based design accreditation and certification", ''Health Facilities Management'', July 2009.
* Kirk, Hamilton D., "Research Informed Design & Outcomes for Healthcare" in ''Evidence Based Hospital Design Forum'', Washington, January 2009.
* Stankos, M. and Scharz, B., "Evidence-Based Design in Healthcare: A Theoretical Dilemma", ''IDRP Interdisciplinary Design and Research e-Journal'', Volume I, Issue I (Design and Health), January 2007.
* Ulrich, R.S., [https://www.brikbase.org/sites/default/files/Roger-Ulrich-WCDH2000.pdf "Effects of Healthcare Environmental Design on Medical Outcomes"] in ''Design & Health – The therapeutic benefits of design, proceedings of the 2nd Annual International Congress on Design and Health''. Karolinska Institute, Stockholm, June 2000.
* Webster, L. and Steinke, C., "Evidence-based design: A new direction for health care". ''Design Quarterly'', Winter 2009
* Sadler, B.L., Dubose, J.R., Malone, E.B. and Zimring, C.M., "The business case for building better hospitals through evidence based design". White Paper Series 1/5, ''[http://hcleader.healthdesign.org/whitepapers.html Evidence-Based Design Resources for Healthcare Executives]'', Center for Health Design, September 2008.
* Ulrich, R.S., Zimring, C.M., Zhu, X., Dubose, J., Seo, H.B., Choi, Y.S., Quan, X. and Joseph, A., "A review of the research literature on evidence based healthcare design", White Paper Series 5/5, ''[http://hcleader.healthdesign.org/whitepapers.html Evidence-Based Design Resources for Healthcare Executives]'', Center for Health Design, September 2008.

==Further reading==
* ''A Visual Reference to Evidence-Based Design'' by Jain Malkin.
* ''Study Guide 1: An Introduction to Evidence-Based Design: Exploring Healthcare and Design''.
* ''Study Guide 2: Building the Evidence-Base: Understanding Research in Helathcare Design''.
* ''[https://web.archive.org/web/20090225075630/http://healthdesign.org/edac/examstudyguide.php Study Guide 3: Integrating Evidence-Based Design: Practicing the Healthcare Design Process]''.
* ''[https://web.archive.org/web/20090215172833/http://healthdesign.org/resources/pubs/PractitionerGuide.php A Practitioner's Guide to Evidence-Based Design]'' by Debra D. Harris, PhD, Anjali Joseph, PhD, Franklin Becker, PhD, Kirk Hamilton, FAIA, FACHA, Mardelle McCuskey Shepley, AIA, D.Arch.
* ''Evidence-Based Design for Multiple Building Types'' by D. Kirk Hamilton and David H. Watkins.
* Stout, Chris E. and Hayes, Randy A. ''The evidence-based practice: methods, models, and tools for mental health professionals''. John Wiley and Sons, January 2005.
* Ulrich, R., Quan, X., Zimring, C., Joseph, A. and, Choudhary, R., "The Role of the Physical Environment in the Hospital of the 21st Century". Report to the Center for Health Design, September 2004.
* Cama, R., (2009). ''Evidence-Based Healthcare Design''. Hoboken, New Jersey: John Wiley & Sons, Inc. 
* Phiri, M. (2015). ''Design Tools for Evidence-Based Healthcare Design''. Abingdon & New York: Routledge.
* Phiri, M. & Chen, B. (2014). ''Sustainability and Evidence-Based Design in Healthcare Estate''. Heidelberg: Springer.

==External links==
* [http://www.healthdesign.org: The Center for Health Design]
* [https://web.archive.org/web/20070416222819/http://www.healthdesign.org/research/reports/physical_environ.php Role of the Physical Environment in the Hospital of the 21st Century]: Report published by The Center for Health Design in 2004 summarizing evidence-based design research for healthcare
* [https://web.archive.org/web/20090601151248/http://www.informedesign.umn.edu/ InformeDesign]: Research database of studies linking environment to outcomes
* [http://chsd.arch.tamu.edu Center for Health Systems and Design]
* [https://www.picker.org/ Picker Institute]
* [https://web.archive.org/web/20111223011131/http://www.sph.tulane.edu/cebgh/ Tulane Center for Evidence-Based Global Health]

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[[Category:Health care quality]]
[[Category:Decision-making]]
[[Category:Health informatics]]
[[Category:Evidence-based practices]]

{{Sourceattribution|Evidence-based design}}