This paper will define evidence-based design and identify outcomes of evidence-based design in healthcare. Two examples will be provided of areas where evidence can – and should – be integrated into healthcare facility design, in order to optimally support healthcare workers and patients.

1. EVIDENCE-BASED DESIGN:
DEFINITION AND APPLICATION IN THE
HEALTHCARE SETTING
LORISSA MACALLISTER, PHD, AIA, NCARB, LEED AP, EDAC
PRESIDENT AND FOUNDER OF ENVIAH
SENIOR RESEARCH FELLOW AT THE SAMUELI INSTITUTE

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As such, they cannot be reproduced or utilized without permission. ©2016
Introduction
Hospitals and health systems face many challenges
in today’s rapidly changing healthcare market:
consolidation of facilities, mergers and acquisitions,
new measurements of performance, workforce
shortage issues, and an increased demand for
experience-based healthcare. To weather these
changes, it is crucial that organizations know how to
improve their performance and identify the factors
that are essential to their success. In healthcare and
other industries, the built environment has long been
recognized as playing a crucial role in organizational
success.
The architectural design process historically includes
identifying space based on volume, defining peaks,
and building space to support that need. In the last
decade, however, architectural work has begun to
shift away from traditional planning models that
project space needs through volume analysis.
Instead, the approach has shifted to a multi-modal
model that focuses on the experience of the occupant
and incorporates evidence-based research into the
planning process.
Recent studies have looked not only at space, but also
at how spatial layout may impact a specific desired
outcome (e.g., medical errors or worker injuries). 1,2
While workplace culture undoubtedly influences these
outcomes, the environment and the spatial layout can
also be a barrier to the full realization of organizational
goals.3,4,5
In addition to making infrastructure choices
based on operational and maintenance requirements,
healthcare architects and designers must also consider
key environmental factors and design choices that
impact building occupants.5
There has been a shift in many industries, especially
in the new economy, which warns that we will not be
able to build our way to success – we need to instead
build smarter. This paper will define evidence-based
design and identify outcomes of evidence-based
design in healthcare. Two examples will be provided of
areas where evidence can – and should – be integrated
into healthcare facility design, in order to optimally
support healthcare workers and patients.
What is Evidence-Based Design?
Finding new ways to measure success and apply it
to the field of healthcare is at the heart of the field
called Evidence-Based Design (EBD).6
With the Center
for Health Design’s (CHD) formal establishment of the
field of Evidence-Based Design in 1993, researchers
began in earnest to study the interplay of design,
environments and occupant health.
Steps in the Evidence-Based
Design process:7
1. Define evidence-based goals and
objectives.
2. Find sources for relevant evidence.
3. Critically interpret relevant evidence.
4. Create and innovate evidence-based
design concepts.
5. Develop a hypothesis.
6. Collect baseline performance measures.
7. Monitor implementation of design and
construction.
8. Measure post-occupancy performance
results.
According to the
CHD, evidence-based
design is the process of
basing decisions about
the built environment
on credible research
to achieve the best
possible outcomes.7

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The information and concepts contained in this document are the proprietary property of Sodexo.
As such, they cannot be reproduced or utilized without permission. ©2016
Before the launch of the reimbursement tool in the 1995 Consumer Assessment of Healthcare Providers and
Systems program (CAHPS), healthcare systems were not incentivized to improve patient well-being. Instead,
hospitals aimed to quickly fix patients’ symptoms and move them through the system. As a result, designers and
architects in healthcare focused on creating environments that supported quick throughput.
Today, the tides are changing. The recent focus on patient satisfaction has emphasized the need to more carefully
consider the built environment. At the same time, the healthcare industry faces a growing workforce shortage
and struggles to attract and retain skilled staff. Research shows that staff, patients, physicians, and payers view
the facility and its characteristics as an attribute of quality – which translates to increased patient and staff
satisfaction, and greater market share.8
A large and growing body of evidence attests to the fact that the physical environment in healthcare settings
impacts quality of care, patient stress, patient and staff safety, staff effectiveness, recruitment and retention
of staff, operational efficiency and ultimately, the financial bottom line. Basing healthcare facility planning and
design decisions on this evidence to achieve the best possible patient, staff and operational outcomes is what
evidence-based design is all about.
Outcomes of Evidence-Based Design in Healthcare
There are over 1,200 credible studies on how an environment can impact its occupant, but more research is
needed that focuses on the healthcare setting. As Barry Rabner, CEO of the University Medical Center of Princeton,
emphasizes, antibacterial floors sound like a great idea—but to justify their cost, architects and others in the
design process need to document their efficacy.9
Unfortunately, controlled studies in hospitals are difficult to
implement, due to the many possible confounders that make it hard to isolate a causal outcome or link.
In 2012, researchers conducted a review of the impact of physical environmental factors on users in healthcare
facilities.10
The review investigated and structured the scientific research on evidence-based healthcare design and
outcomes for patients, their families and staff (see Figure 1). The studies evaluated in the review found that the
physical environment has a positive effect on all of these outcomes, but much of the available evidence focuses
on comfort. There is a scarcity of evidence for some outcomes and specific to staff, indicating the need for further
research.

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As such, they cannot be reproduced or utilized without permission. ©2016
Figure 1. Topics and Subtopics examined in a Systematic Review of the Impact of
Physical Environmental Factors on Patients, Families, and Healthcare Staff10
Users Topics Subtopics
Patients
Family/
Relatives
Staff
No errors
Safety & Security
Control
Privacy
Comfort
Technical Support
Organization &
Functionality
Family Support
Identical rooms
Lighting
Reduce falls
Reduce infection
Hygiene/Cleanliness
Accessibility
Indoor quality
Single patient room
Waiting room
Art
View
Visual Comfort
Acoustic Comfort
Orientation
Materials
Orientation
Way-finding
Lighting
Ergonomics

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The information and concepts contained in this document are the proprietary property of Sodexo.
As such, they cannot be reproduced or utilized without permission. ©2016
It is essential that healthcare architects understand and apply this information during all phases of the design and
building processes, yet few have an expert understanding of medicine and research methodology. As a discipline,
evidence-driven healthcare architecture is still in its infancy. Architects are taught to design a space that meets
the client’s needs and deadlines, while maintaining safety and constructability. They are typically not taught to
design spaces that enhance occupants’ health, satisfaction, or worker performance.
In the remainder of this paper, we examine two areas where evidence can be integrated into healthcare facility
design, in order to optimally support healthcare workers and patients. Specifically, we discuss the evidence
supporting (1) environmental factors affecting patient stress, and (2) the impact of unit design on healthcare
worker effectiveness.
Indoor Environmental Factors and Patient Stress
Stress is a known factor in health, and can be a significant barrier to healing. In Ulrich’s landmark 1984 study, he
discovered that views of nature can decrease patient stress, reduce the need for pain medication, and shorten the
length of stay.11
In more recent research, Rashid and Zimring developed a framework for interior environmental
factors that can positively or negatively influence stress.12
These include noise levels, lighting, room temperature,
room layout, window placement, and orientation.13,14,15,16,17
With respect to noise levels, the ability to overhear conversations can impact patient stress levels and feelings of
security.14
Unpredictable noises (e.g., a door slamming) are more disruptive and stress-inducing than a continuous
noise at a uniform level.13,15,16
Lighting is another environmental stressor for some populations. For autistic children
and Alzheimer’s patients, cool florescent lights that have a constant flicker can cause them to feel agitated.18,19
Healthcare facility designers should take these and other factors into consideration in order to support a stress-
free environment.
Patient stress is
influenced by:
§§Noise levels
§§Lighting
§§Room temperature
§§Room layout
§§Window placement
§§Views of nature
§§Orientation

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As such, they cannot be reproduced or utilized without permission. ©2016
Unit Design and Employee Effectiveness
With the increased strain being placed on healthcare
workers, there is a greater need for the alignment
of a building to its functional purpose. The physical
distance from the observation area, nurse station,
or hub of inpatient unit activity has been the topic of
many research studies. In particular, the location of
the nurses’ station relative to the inpatient unit, and
the effect this has on patients, has been an important
consideration for designers.
UK-based architect Paul James’ global survey of
inpatient units was a significant contribution to the
field because it identified the components and forms
of hospital unit designs and how they impact patients
and staff.20
His work included an in-depth review of the
location of nurses’ stations and their travel distances
to patient rooms, which were found to vary greatly.
His work became a valuable resource, as it quantified
many of the planning concepts that had been used for
decades and helped to move the industry to further
challenge the status quo.
More recent research has found that in units with
shorter distances from nurse stations to patients’
rooms, such as decentralized nursing, patients have
better care experiences. In these rooms, nurses
interact more with the patients 21
and have reduced
walking distances and increased care time.22
Conclusion
The field of evidence-based design centers upon
achieving the best possible outcomes for building
occupants, through a process in which decisions about
the built environment are based on credible research.
A growing body of evidence links environmental
factors to myriad positive outcomes for patients,
staff and the healthcare organization. Building design
and performance must therefore be considered not
just from an infrastructure perspective, but from a
functional and behavioral perspective as well. As
the body of research supporting the link between
the environment and occupant outcomes continues
to grow, evidence-based design will also evolve and
play a much more crucial role in the design and
architecture of healthcare facilities.
In units with
shorter distances
from nurse
stations to
patients’ rooms,
patients have
better care
experiences.

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The information and concepts contained in this document are the proprietary property of Sodexo.
As such, they cannot be reproduced or utilized without permission. ©2016
References
1. Cai, H., & Zimring, C. (2012). Out Of Sight, Out Of
Reach: Correlating spatial metrics of nurse station
typology with nurses’ communication and co-
awareness in an intensive care unit. Paper presented
at the Eighth International Space Syntax Symposium,
Santiago de Chile.
2. Choi, Y., Lawler, E., Boenecke, C., Ponatoski, E. R.,
& Zimring, C. (2011). Developing a multi-systemic
fall prevention model, incorporating the physical
environment, the care process and technology: a
systematic review. Journal of Advanced Nursing,
67(12), 2501-2524.
3. Brown, Z., Cole, R. J., Robinson, J., & Dowlatabadi, H.
(2010). Evaluating user experience in green buildings
in relation to workplace culture and context.
Facilities, 28(3/4), 225-238.
4. Cai, H., & Zimring, C. (2011). Nursing Culture and
Performance: The impact of nursing station typology
on nurses’ informal communication and learning.
Design and Health Scientific Review, July, 60-67.
5. Salonen, H., Lahtinen, M., Lappalainen, S.,
Nevala, N., Knibbs, L. D., Morawska, L., & Reljula,
K. (2013). Physical characteristics of the indoor
environment that affect health and wellbeing in
healthcare facilities: A review. Intellegent Buildings
International(5), 3-25.
6. Zimring, C., & Bosch, S. (2008). Building the
Evidence Base for Evidence-Based Design: Editors’
Introduction. Environment & Behavior, 40(147), 147-
150.
7. The Center for Health Design. (2015). About.
Retrieved from https://www.healthdesign.org/
certification-outreach/edac/about
8. Stichler, J. F. (2007). Using Evidence-Based
Design to Improve Outcomes. Journal of Nursing
Administration, 37(1), 1-4.
9. Kimmelman, M. (2014, August 21). In Redesigned
Room, Hospital Patients May Feel Better Already.
New York Times.
10. Huisman, E. R. C. M., Morales, E., van Hoof, J., & Kort,
H. S. M. (2012). Healing environment: A review of the
impact of physical environmental factors on users.
Building and Environment, 58, 70-80.
11. Ulrich, R. (1984). View through a window may
influence recovery from surgery. Science, 224(4647),
420-421.
12. Rashid, M., & Zimring, C. (2008). A Review of the
Empirical Literature on the Relationships between
Indoor Environment and Stress in Health Care and
Office Settings: Problems and Prospects of Sharing
Evidence. Environment & Behavior, 40(2), 151-190.
13. Glass, D. C., & Singer, J. E. (1972). Urban stress:
Experiments on noise and social stressors. New York,
NY: Academic Press.
14. Hagerman, I., Rasmanis, G., Blomkvist, V., Ulrich,
R., Eriksen, C., & Theorell, T. (2005). Influence of
intensive coronary care acoustics on the quality
of care and the physiological state of patients.
International Journal of Cardiology, 98(2), 267-270.
15. Kjellberg, A., Landstrom, U., Tesarz, M., Soderberg,
L., & Akerlund, E. (1996). The effects of nonphysical
noise characteristics, ongoing task and noise
sensitivity on annoyance and distraction due to
noise at work. Journal of Environmental Psychology,
16(2), 123-136.
16. Sundstrom, E., & Sundstrom, M. G. (1986). Work
places: The psychology of the physical environment
in offices and factories: Cambridge University Press.
17. Zimring, C, Weitzer, W., & Knight, R. (1982).
Opportunity for Control and the Design Environment:
The Case of an Institution for the Developmentally
Disabled. In S. J. Baum A (Ed.), Advances in
Environmental Psychology (Vol. IV, pp. 171-209).
Hillsdale NJ: Lawrence Erlbaum Associates.
18. Carpman, J. R., & Grant, M. A. (1993). Design that
cares: Planning health facilities for patients and
visitors (2nd ed.). Chicago Il.: American Hospital
Publishing.
19. Colman, R. S., Frankel, F., Ritvo, E., & Freeman, B. J.
(1976). The effects of fluorescent and incandescent
illumination upon repetitive behaviors in autistic
children. Journal of Autism and Child Schizophrenia,
6(2), 157-162.
20. Tatton-Brown, W., & James, P. W. (1987). Hospitals:
Design and Development: Architectural Press.
21. Ulrich, R., Zimring, C., Quan, X., Joseph, A.,
& Choudhary, R. (2004). Role of the Physical
Environment in the Hospital of the 21st Century. The
Center for Health Design.
22. Hendrich, A. L., Fay, J., & Sorrells, A. K. (2004). Effects
of acuity adaptable rooms on flow of patients and
delivery of care. Journal of Critical Care, 13(1), 35-45.

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