Evidence-Based Design in Healthcare

• Chapter focuses on how to be able to understand research in the context of evidence-based design, identify sources for relevant evidence within a healthcare facility and to identify the role research can play to improve outcomes

Introduction

• Evidence-based design (EBD) involves basing decisions about the built environment on credible research to achieve the best possible outcomes
• The process starts with an interdisciplinary team forming a vision and goals for the project
• Subsequently, the team determines how to achieve these goals using design strategies, technology, cultural transformation, and re-engineered processes

EBD Value

• EBD focuses on significantly improving health care quality, safety, and being patient and family-centered
• EBD uses innovative approaches to achieve improvements
• Even with a well-conceived EBD project, testing concepts or hypotheses may still lead to poor outcomes
• Scientific research is about proposing, testing, and rejecting ideas, and combining prior research to improve models

Empirical Research

• Empirical research is the systematic investigation of tangible facts
• It aims to gain knowledge, make discoveries, test or revise theories, and apply new knowledge
• Empirical data is information that can be directly sensed and demonstrated
• Examples of empirical data include noise levels measured by sound-level meters, inpatient length of stay, and staff interaction observations
• Subjective data gathered through interviews, surveys, and rating scales is also considered empirical

Integrating EBD

• EBD process integration should start after an organization decides to undertake a project and define its goals
• Research plays a pivotal role in the EBD process which allows for empirically evaluated design solutions and new evidence
• Basic research knowledge is needed for successful EBD implementation

Evidence-Based Design (EBD)

• EBD has two main inseparable elements evidence and design
• Evidence proves or disproves something and is gathered from research
• Research data can be gleaned from already existing previous studies, may need to be organized (such as internal data), or need to be collected in a new research study
• Guide 2: focuses on the key elements of EBD research and the detailed research process of using existing evidence and creating new evidence, and the different types and methods of research to closely examine, evaluate, and use existing evidence
• The chapter provides an overview of how to use research for design, understand evidence, and create new evidence

Using Research to Inform Design

• Core of EBD is linking research and design
• EBD differs from traditional design through its focus on using research to inform and support design decisions and to evaluate design strategies and innovations
• EBD is employed throughout a projects lifecycle

Predesign and Design

• Finding and using research is important during both the predesign and design phases
• After developing project vision, goals, and objectives, relevant research guides development of design concepts, helps evaluate existing design options, and sparks design innovations
• This is when individuals practicing EBD develop a hypothesis and translate evidence into design decisions
• EBD can use small-scale or pilot projects to test a product or design innovations effectiveness

Research in Practice at PeaceHealth

• Stakeholders should consider research to assist in understanding which environmental elements are the best design options to improve outcomes
• Ulrich et al. (2008) references studies evaluating the impact of ceiling lifts on staff outcomes, finding that they reduce physical stress and strain from patient handling and reduce the incidence of injury claims
• PeaceHealth in Eugene, Oregon, integrated this into their Sacred Heart Medical Center (SHMC)'s planning stage, exploring mechanical devices alongside a no-manual-lift policy to address back injuries from patient lifting
• PeaceHealth installed ceiling lifts in 26 of 33 ICU rooms at its River Bend, OR, facility and in 24 neurology rooms
• Over a 60-month period (January 2001 to December 2006), there were 10 patient handling-related injuries in the ICU in the 2 years before ceiling lift installation, costing $142,500 annually
• After installing lifts in over 75% of the rooms, no injuries occurred during the study period due to moving patients using the lifts
• In neurology, 15 patient handling-related injuries occurred in the 3 years before lift installation, costing $222,645 annually
• In the 2 years after installation, six injuries occurred, some with extenuating circumstances, such as failure to use the lift
• The annual cost after installation was $54,660
• PeaceHealth made all 309 rooms lift ready, installed 234 transverse rails and lifts, and projected a 2.5-year ROI

Stakeholders

• Providing a common language between stakeholders facilitates improved communication
• Designers are able to more effectively communicate design options with owners
• Resolving disagreements is easier

Improve Documentation and Tracking

• Research leads to better documentation and tracking during design
• Documenting the literature reviewed in a research repository makes information available for later review and decisions

Testing Theories

• Research can test how evidence supports theories
• Researchers then refine theories and test them again
• New research adds to the existing knowledge base

Case Study: Moncrief Cancer Institute

• Patients often feel they lack control during cancer treatment
• Providing a caring environment gives patients control and reduces stress
• By providing a choice of infusion room layouts, goals include increasing satisfaction and enhancing hope, and also encourage social interaction
• UT Southwestern Medical Center and Moncrief Cancer Institute use for EBD is a natural fit since both entities desired a unique care environment like a nationally known cancer care center
• Prior to design work, a literature review was done to get information, which was then combined to form the design for the Moncrief Cancer Institute infusion center
• Designs include patient selection from three room layouts & community spaces for patients/care partners reduced side effects and increased patient satisfaction within 72 hours

Facility Vision

• The 30,000 square-foot facility brings services like chemotherapy, diagnostic imaging, therapies and National Cancer Institute clinical research trials to Moncrief Cancer Institute's programs
• At the project start, the Corgan design team conducted a visioning session with stakeholders
• The vision was for a balanced, clean, and modern facility

Infusion Areas

• Private, semi-open, and open designs were studied
• Angled room design gives the patient a choice depending on treatment day
• Option 1 orients the patient to the community space to encourage more social interactions, option 2 provides patients with a view of the healing garden, and option 3 places infusion rooms away from the window for sunlight sensitivity
• Community spaces have innovative seating to encourage socialization, and chairs are arranged to allow infusion buddies to socialize, baseline performance will be collected, and post-occupancy results will be measured

Research Quality and Application

• Research and application of research makes decisions and has credibility for leaders
• Evidence includes research studies, professional practice articles, and reports

Research Findings

• Factors such as research methods affects research findings
• Multiple studies can have conflicting results
• To be effective, design teams should evaluate and combine evidence
• Ulrich et al. (2004)'s literature review provided a framework that linked hospital design with clinical outcomes as one evaluation

Ulrich et al. (2008) Study

• Ulrich et al. (2008) found that EBD improves safely primarily by reducing the risk of hospital-acquired infections
• Physical environment impacts nosocomial infection rates by impacting air, contact, and water routes
• Infection rates are lower when there is good air and water quality plus greater physical separation, isolation, or space per patient
• Key areas design affects that certain design characteristics impact patient and staff outcomes are: reduction in staff stress and fatigue, improvement in patient safety, reduction in patient stress, and improvement in overall health care quality
• Ulrich et al. (2008) conducted another analysis from 2004-2007, searching for empirical studies linking design to health care outcomes
• They screened references with criteria and studies were empirically based and peer reviewed

Outcomes

• Outcomes were: patient safety issues such as infections, medical errors, and falls ; other patient outcomes like pain, sleep, stress, depression, length of stay, spatial orientation, privacy, communication, social support, and overall patient satisfaction; and staff outcomes like injuries, stress, work effectiveness, and satisfaction
• Ulrich et al. (2008) found that there is a huge need for improved healthcare facilities
• Health facilities capability to make hospitals less risky, stressful and more healing for patients and to provide better staff places to work

The Center for Health Design's Knowledge Repository

• The Knowledge Repository is a central location for EBD references and articles, and is a bridge between practice and research to facilitate design in practice
• It has over 2,500 references from CHD's literature reviews and sources from two decades that will be tagged with health care outcomes, environmental conditions, design categories, and facility types
• Key point summaries for research articles make for easy to understand analyses to the resource

Randomized Controlled Trial

• A randomized controlled trial or experiment has the strongest credible data, but these randomized controlled trials linking design to health care outcomes are hard to find
• Environmental features are affected by physical changes, and many variables are created so it is hard to connect impact on health care to one independent effect
• Reliable patterns are found across studies with respect to outcome influences.

Literature Reviews

• Literature reviews require know-how on using research databases and abstracts to organize the information.
• The Center for Health Design's Knowledge Repository this aids teams in finding research

Creating new Evidence

• Research is important for design decisions. Research should be done/considered after construction/occupancy
• Results of research should be shared to contribute to the industries information base
• Once construction is done, conduct research to rate effectiveness of different strategies
• Research answers questions and informs about design strategies like sound-absorbing ceiling tiles, daylight, gardens, location and layout of stations, depts, and new innovations
• Research is used to test theories, findings can be used to see whether or not evidence supports theories
• Based on results that researchers can test, new research contributes with publishing research
• This practice can greatly contribute to the field and significantly expand knowledge

Environmental of Care (EOC)

• The Environment of Care (EOC) defines health care, which is comprised of:
• Delivery of care model (concepts)
• Facility and service users (people)
• Systems design
• Layout and operational planning
• Physical environment
• Design process and implementation
• EOC components are the measurement of temperature, light, sound, location, materials, or equipment in the care setting
• Data exist through studies to be organized or be created
• Information for health status, performance, safety, injuries, along with operational factors are a part of every healthcare company
• Data are collected with diagnostic data during their care
• Information is in medical records/ databases for best practices
• This can be used for building data to find how changes relate to health, performance, staff/patient satisfaction and economic outcomes

Valid and Reliable Measurements

• Device must measure for environmental variable being valid and reliable
• Studies state short wavelength light is very effective, and long-wavelength red light influences cardiac
• Photometers measure light, but are inaccurate with blue and red, and dosimeters gauge sound frequencies in speech, however are inaccurate with high/low
• Sophisticated measurement devices, a broader range of information environmental can be calculated with info recorded at healthcare
• Survey data collected such as "Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)"
• This would ask environment questions, but not specific enough to establish "causal relationship between design and patient satisfaction"
• It is important to consider how can improve the impact to get results

HCAHPS

• HCAHPS surveys ask a patient about communication and has 3 outcomes when rated low
• It would show the team communication, lack of time with the patient, or excellent skills, but not be heard from noise levels
• Space that supports communication, increase time, or have space in presence of noise
• Specific evaluation of the built conditions make it hard since the design cannot support strategies
• Researches can make suppositions to a relationship between design change and outcome measures

Conclusion

• To show causal relationships between environment and outcomes, specific environment, staff exposure, and patient are key
• Once measured, the evidence should be looked to application for design Basic research to inform, understand and evaluate evidence
• Design helps research to make scientific design, by healthcare and patients for decision