1) Evidence-based design (EBD) emerged in healthcare to improve safety and outcomes using research-informed design decisions. 2) Studies found EBD strategies like decentralized nursing units reduced patient falls by 75% and transfers by 90%. 3) Other research linked factors like patient visibility and private rooms to lower mortality and infection risk. 4) For BIM to be truly evidence-based, it needs an empirical evidence base from built project performance and linkage to organizational goals, not just cost savings.

1. Beyond a Reasonable Doubt
Can (or Should) BIM be Evidence-Based?
Dr. Debajyoti Pati HKS Architects 14 October 2010

2. Presenter
Debajyoti Pati
PhD, FIIA, LEED©AP
Vice President, Director of
Research, HKS Architects
Executive Director,
Center for Advanced Design
Research & Evaluation
(CADRE)

3. Learning Objectives
1. Understand factors that contributed to the emergence
of the EBD model
2. Understand the fundamental essence of the EBD
practice model in healthcare
3. Illustrate how physical design is being linked to
organizational performance and bottom line
4. Explore the implications of mapping the EBD model to
BIM

4. Agenda
 What is EBD and how it emerged?
 What changes is it effecting?
 Healthcare examples
 Implications for BIM
 Discussions

5. What is Evidence-Based Design
 Evidence-based design
is the conscientious,
explicit and judicious
use of current best
evidence from research
and practice in making
critical decisions,
together with an
informed client, about
the design of each
individual and unique
project.
(Center for Health Design)
 Is a natural parallel and
analog to evidence-
based medicine.
 Applicable to all
buildings sectors.
 Started in the
healthcare sector.

6. Emergence of EBD
 1999
• Institute of Medicine
(IOM)published a report
underscoring the need for
a safer healthcare system
o 44,000 to 98,000
preventable deaths
o Deaths from preventable
medical errors exceed
deaths from motor
vehicle accident, breast
cancer and AIDS.

7. Emergence of EBD
 2001, 2003
• Agency for Healthcare
Research and Quality
(AHRQ) highlighted the
role of the physical
environment (in addition
to the people, processes
and procedures) in
improving care quality
and safety.

8. EBD :: EBM
 The conscientious,
explicit and judicious
use of current best
evidence in making
decisions about the care
of the individual patient.
 Integrating individual
clinical expertise with
the best available
external clinical
evidence from
systematic research.
(Sackett D, 1996)
 EBM is the integration
of clinical expertise,
patient values, and the
best evidence into the
decision making
process for patient care.

9. CHANGING THE DESIGNER – CLIENT
DYNAMICS

10. Designer’s Role
 Respond to
programmatic needs

11. Designer’s Role
 Understand:
• core organizational
needs
• business processes
SURGERYDECISIONPRE-PROCEDUREPROCEDUREPOST-PROCEDURE

12. Designer’s Role
 Identify strategic
organizational
objectives/ goals to be
targeted through
physical design

13. Designer’s Role
 Identify and articulate
relationships between
physical design
decisions and
organizational
outcomes based on
best available
evidence

14. Designer’s Role
 Conduct research to
inform decision-making
if evidence is not
available

15. Designer’s Role
 Implement evidence-
based decision
 Assess outcomes
Predictable
outcomes based
on available data
New knowledge
through research
Identify
Intentions/ Issues
Develop
Hypotheses
Informed
DESIGN
Collect
DATA
Evaluate
Data
Modify
Hypotheses
Disseminate
Findings
Survey
Literature
Return on Investment (Hard and Soft)

16. FROM ACTIVE RESPONSE TO
PROGRAMMATIC NEEDS TO
‘PREDICTABLE’ INFLUENCE ON
OUTCOMES OF ORGANIZATIONAL
INTEREST

17. HEALTHCARE EXAMPLES

18. Organizational Outcomes of Interest
 Reduce patient falls
• Cost =10K un-litigated
 Reduce patient transfer
• Cost per transfer = $ 300
 Reduce hospital
acquired infection
• Cost per infection = 10-
30K
 Nurse retention
• Cost per recruitment =
60K
 Patient satisfaction
 Market segment,
referrals
 …

19. Patient Falls: Clarian Methodist Study
Objective: Test impact on new
acuity adaptable unit design on
patient outcomes
Decentralization
Room-side documentation alcove
Location: CCCC, Methodist
Clarian, Indianapolis
Procedure: Before-after study, 12
outcome measures, 2 years
baseline and 3-years post-move
data
Key finding: Patient falls declined
by 75%
Hendrich, A., Fay, J., & Sorrels, A.K. (2004). Effects of Acuity-Adaptable Rooms on Flow of
Patients and Delivery of Care. American Journal of Critical Care, 13(1), 35-45.

20. Patient Transfer: Clarian Methodist Study
Objective: Test impact on new
acuity adaptable unit design on
patient outcomes
Patient rooms designed to
accommodate varying acuity levels
Location: CCCC, Methodist
Clarian, Indianapolis
Procedure: Before-after study, 12
outcome measures, 2 years
baseline and 3-years post-move
data
Key finding: Patient transport
decreased by 90%
Hendrich, A., Fay, J., & Sorrels, A.K. (2004). Effects of Acuity-Adaptable Rooms on Flow of
Patients and Delivery of Care. American Journal of Critical Care, 13(1), 35-45.

21. Patient Visibility: Stanford-Harvard Study
Objective: Contrast safety concerns of
frontline staff with national patient safety
initiatives
Funding: AHRQ + Fishman-Davidson
Center for Service and Operations
Management
Location: 20 representative sample of
hospitals across the U.S.
Data Source: 1,732 staff-identified
operational failures (2004 – 2006)
Key finding: Top factors affecting
safety: Equipment and Facility
Tucker, A., Singer, S., Hayes, J., & Falwell, A. (2008). Front-line Staff Perspectives on
Opportunities for Improving the Safety and Efficiency of Hospital Work Systems. Health
Services Research, 43(5), 1807-1829.

22. Stanford-Harvard Study: Failure Sources
 Equipment/ Supply
(18%)
 Facility (18%)
• Layout
• Maintenance +
Housekeeping
• Non-functioning
infrastructure
 Communication/
Documentation (16%)
 Staffing/staff
development (16%)
 Medication (12%)
 Process/policy (6%)
 Response time (4%)
 Security (4%)
 Infection control (3%)
 Task management (2%)
Tucker, A., Singer, S., Hayes, J., & Falwell, A. (2008). Front-line Staff Perspectives on
Opportunities for Improving the Safety and Efficiency of Hospital Work Systems. Health
Services Research, 43(5), 1807-1829.

23. Patient Visibility: Columbia University Study
Objective: Assess whether
patient outcomes are affected by
ICU design
Location: Columbia University
Medical Center, Medical ICU;
random room assignment
Data Source: 664 patients;
hospital mortality, ICU mortality,
ICU LOS, ventilator-free days
Key finding: Severely ill patients
had significantly higher mortality
in low-visibility rooms; 18%
higher
Leaf, D., Homel, P., & Factor, P. (2010). Relationship between ICU Design and Mortality. Chest,
Pre-published online January 15, 2010.

24. Infection: Canadian HAI Study
Objective: Evaluate association
between roommate exposure and
risk of HAIs
Location: A tertiary care teaching
hospital in southeastern Ontario
Procedure: Retrospective data on
adult patients between 2001 –
2005; MRSA/VRE; C difficile; total
roommates, unique roommates
Key findings: each additional
roommate
• 11% increase in C difficile risk
• 10% increase in MRSA risk
• 11% increase in VRE risk
Hamel M, Zoutman D, O'Callaghan C. (2010). Exposure to hospital roommates as a risk factor for
health care-associated infection. American Journal of Infection Control, 38(3), 173-181.

25. The PEBBLE Project Data Repository
 PEBBLE
• Launched by the Center
for Health Design in
2000
• ~ 60 member hospitals
• Before-after and post-
occupancy data in a
central database

26. IMPLICATIONS FOR BIM

27. BIM Objectives
 Enhance facility
procurement
performance
 Predict built facility
performance
• Energy
• Maintenance
• Lighting
• …

28. BIM Status
 Sophisticated
performance models
 Assertions untested
• Little empirical evidence
from built facilities to
support contentions
 Similar to LEED status
 Standardization of
performance
measurement protocol
emerging…
• ASHRAE, USGBC,
CIBSE

29. Key Question
SHOULD BIM BE EVIDENCE-BASED?

30. Next Steps
Evidence
Base
Client
Needs

31. Evidence Base
 Post-occupancy
performance
 Pebble type
commitment
 Central data base

32. Organizational Needs
 Framing BIM within
organizational needs
• Controlling airborne
infection may be more
crucial than saving on
HVAC cost…
 Situating BIM within the
larger context of
organizational
performance
• It is not necessarily about
more economic first and
life cycle cost
• It is about optimizing
facility performance to
target organizational
goals

33. A DIFFERENT NATURE OF
RELATIONSHIP WITH CLIENT
ORGANIZATIONS
MUST START WITH EVIDENCE
Where is the evidence?

34. THANK YOU