Evidence-based design: Difference between revisions

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

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{{Evidence-based practices}}

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'''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 [[evidence-based medicine]], where research has shown that environment design can affect patient outcomes. It is also used in [[architecture]], [[interior design]], [[landscape architecture]], [[facilities management]], [[Evidence-based education|education]], and [[urban planning]]. Evidence-based design is part of the larger movement towards [[evidence-based practices]].

Although much attention in healthcare is paid to clinical issues and to the medical care patients receive, recently little attention has been paid also to the physical space where patient stay. Evidence-based design (EBD) is an approach to healthcare design that give importance to design features that impact patient health, well-being, mood, and safety, as well as staff stress and safety. The approach focused on the relations between the quality and the features of the hospital environment and the patient healing.

== Background ==

EBD is the process of basing decisions about the built environment on credible research to achieve the best possible outcomes ([http://www.healthdesign.org The Center for Health Design], 2008).

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-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.” (Hamilton, DK & DH Watkins 2009)

''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 [[Nonprofit organization|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"/>

It is created by a growing body of research showing that a proper design of the built environment contributes to improve key outcomes both patient and staff oriented. Some of these are: encourage patient healing, increasing patient and staff safety, reducing patient and staff stress, improving patient and family satisfaction, increasing staff effectiveness, reducing staff turnover, and consequently reducing cost.

Many recent studies have examined how physical environment can influence well-being, promote healing, relieve patient pain and stress, and also reduce medical errors, infections and falls. Many hospitals are adopting elements of evidence-based design in new constructions, expansions or re-modeling.

It is a process used by architects, interior designers, facility managers, and others in the planning, design, and construction of commercial buildings. An evidence-based designer, together with an informed client, makes decisions based on the best information available from [[research]], from project [[evaluation]]s, and from evidence gathered from the operations of the client. Critical thinking is required to develop an appropriate solution to the design problem; the pool of information will rarely offer a precise fit with a client's unique situation and therefore research that is specific to the project's objectives is almost always required. In the last analysis, though, an evidence-based design should result in demonstrated improvements in the organization's [[outcome]]s, [[economic performance]], [[productivity]], [[customer satisfaction]], and [[culture|cultural]] measures.

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.

The process works well in the health-care field but has many relations with complementary fields and some fallouts in distant fields. This approach appeal to many who are directly and indirectly involved in this area of research involves. the positive effect is shown from the patients and families, which have higher-quality stays; physicians, who practice based on medical evidence and the business-minded administrators, who prove this would reduce costs and improve organizational effectiveness.

However, it is applicable to many types of commercial building projects, but is uniquely suited to healthcare because of the unusually high stakes and the financial and clinical outcomes that can be impacted by the built environment. The building itself can help to reduce the stress experienced by patients, their families, and the teams caring for them. The healthcare environment is a work environment for the staff, a healing environment for patients and families, a business environment for the provision of healthcare, and a cultural environment for the organization to fulfill its mission and vision.

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>

Research relevant to healthcare design can come from many areas:

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>

*'''Environmental psychologists''' focus on stress reduction, which includes:

*# social support (patients, family, staff);

*# control (privacy, choices, escape);

*# positive distractions (artwork, music, entertainment);

*# influence of nature (plants, flowers, water, wildlife, nature sounds).

* '''Clinicians''' focus on medical and scientific literature, which includes:

*# treatment modalities (models of care, technology);

*# quality & safety (infections, errors, falls);

*# exercise (exertion, rehabilitation).

* '''Administration''' refers to management literature:

*# financial performance (margin, cost per patient day, nursing hours);

*# operational efficiency (transfers, utilization, resource conservation);

*# satisfaction (patient, staff, physician, turnover).

* '''Evidence-Based Metrics''' includes Research Tools and Methods for Practitioners:

*# Work Measurement PDA (Time Study RN/MD);

*# Design for Efficiency (Layout-iQ);

*# Patient and Resource Workflow (Rapid Modeling).

The evidence-based design movement began in the 1970s with [[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 [[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 evaluation]]s (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]].

Approximately 1200 credible studies with specific environmental relevance have been identified by [http://www.healthdesign.org The Center for Health Design] in these areas, and many more applicable research citations are in other branches of the literature.

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 [[Labour Party (UK)|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==

== Background ==

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

Hospitals designers and administrators main aim is to create a healing space. It could be defined as a space that reduces stress, helps health and healing, and improves patient and staff safety.

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.

The notion of a healing space goes back to ancient Greece: people who were ill looked towareds temples in the hope of having dreams where the God would reveal cures. Later, in 1860, Florence Nightingale fixed ventilation and fresh air as “the very first canon of nursing,” and underline the importance of quietness, proper lighting, warmth, and clean water. Then, a pioneering study conducted by Roger Ulrich in 1984 found that surgery patients with a view of nature suffered fewer complications, used less pain medication, and were discharged sooner than those with a brick-wall view. in addition, studies exist about the psychological effects of lighting, carpeting, and noise on critical-care patients.

currently there are a growing number of evidence that links the physical environment with the improvement of patients and staff safety, wellness and satisfaction.

==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.

EBD continues several research and building practices that have been developed in the 1960s.

For example, in the 1970s in the USA and in the UK architectural researchers have studied the impact of hospital layout on staff effectiveness (Clipson & Johnson 1987; Clipson & Wehrer 1973; Medical Architecture Research Unit, 1971-1977) and social scientists have studied issues such as guidance and [[wayfinding]] (Carpman & Grant 1993). Besides, architectural researchers have explored how [[Post-Occupancy Evaluation (POE)]] provide useful advices to improve design and building quality (Baird, Gray, Isaacs, Kernohan, & McIndoe, 1996; Zimring, 2002).

Today, [http://www.healthdesign.org The Center for Health Design] is focused on EBD practices use and appliance into each step of the design process; more than 600 credible studies with specific environmental design relevance have been identified.

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

== Related approaches ==

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.

=== Performance Based Building Design (PBBD)===

From the perspective of the building industry, EBD is tightly related to [[Performance-Based Building Design]] practices. PBBD, as an approach to design process, attempts to create clear and statistical relationships between design decisions and requirements satisfaction levels evidenced by the building systems. Like EBD, PBBD uses research evidence to predict performance related to design decisions.

however, the decision making process is not a linear one: for the build environment is a complex system. Choices cannot be based on simple cause-and-effect predictions; instead they depend on many variable components and on the mutual relations established one each other. For example, even technical systems such as heating, ventilation, and air-conditioning systems have many interrelated design choices. even related performance requirements, such as energy use, comfort, use cycles, and so on are variable components.

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>

=== Evidence Based Medicine===

[[Evidence Based Medicine]] (EBM) is defined as the systematic process of evaluating scientific research that is used as the basis for clinical treatment choices (Claridge & Fabian, 2005). Sackett, Rosenberg, Gray, Haynes, and Richardson (1996) 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.” (British Medical Journal). It is currently being used in the healthcare industry to help convince decision-makers to invest the time and money to build better buildings and realize strategic business advantages as a result.

As medicine has increasingly moved toward EBM, healthcare design is increasingly going toward approaches that link hospitals’ physical environments to healthcare outcomes, such as EBD.

==Public open space==

== Current state ==

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.

The idea that physical environment can impact patient wellness, staff efficiency, and financial performance has been increasing for about 30 years and has given source to many studies and researches aimed to infer from evidence practical recommendations for healthcare building design.

As EBD becomes more widespread, supported by a growing body of evidence, many healthcare organizations are realzing its importance, are transposing its principles, and trying to build their facilities with the guidance of EBD practitioners. Even though no standards for it have existed until now, recently has been rolled out a certification and the accreditation program by [http://www.healthdesign.org The Center for Health Design]. It has also developed [[Pebble Project]], together with [http://www.informedesign.umn.edu InformeDesign], a not-for-profit clearinghouse for design and human behaviour research. Pebble Project is a joint research effort between the CHD and selected healthcare providers and has the purpose to deepen how to build environments affect patients and staff, and disseminate results.

==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 [[PwC|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==

=== Research centers ===

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.

*[http://www.healthdesign.org The Center for Health Design & Robert Wood Johnson Foundation]

*[http://www.gatech.edu Georgia Tech]

*[http://www.informedesign.umn.edu InformeDesign]

*[http://www.pickerinstitute.org The Picker Institute]

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.

=== Accreditation and cerification ===

The Evidence Based Design Accreditation and Certification (EDAC) program has been rolled out in 2009 by [http://www.healthdesign.org The Center for Health Design] with the purpose to provide nationally recognized accreditation and to promote the use of EBD processes in healthcare building projects. Therefore, its intent is to make EBD an accepted and credible approach to improve healthcare outcomes.

The EDAC is meant to identify qualified experts experienced in EBD practice and to teach about the research process, such as identifying, hypothesizing, implementing, gathering and reporting credible data associated with a health care project.

== 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 [[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 [[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>

== Methodology and strategies ==

In the first instance EBD methodology could be divided in four subsequent steps:

* reviewing existing research literature to select significant findings and recommendations;

* matching referenced findings with data gathered from site visits, surveys results, subject matter experts;

* prediciting the outcomes of design decisions;

* tracking the positive outcomes for design implementation.

Other sources provide different and more specific proceedings to guide practical applications to achieve EBD objectives. Some of them are listed below.

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|bibcode=2000BuRI...28..353H |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"/>

=== Meta-analysis template ===

In his book "Evidence-based Policy: A Realistic Perspective", Ray Pawson (2006) suggests a meta-analysis template that may be applicable for EBD. By using such a protocol the field will be able to provide designers with a credible source for evidence-based design.

Systematic review process should follow six essential steps:

*1. Formulating the review question

*2. Identifying and collecting evidence

*3. Appraising the quality of the evidence

*4. Extracting and processing the data

*5. Systematizing the data

*6. Disseminating the findings

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"/>

=== Conceptual model for the application of EBD ===

According to Hamilton ("Four Levels of Evidence-Based Practice", The AIA Journal of Architecture, 2006), environmental research is more likely to result in performance guidelines than in prescriptive regulation. Different information sources are potentially helpful: literature from psychology, sociology, anthropology, economics, management, engineering, and industrial design. Internet, press, conferences, and exemplary facilities are also good resources. To show evidence-based different types of practice, the model below illustrates four ways of dealing with research. this includes identifiying four increasingly levels and the related methods.

* Level 1

** analysing the literature in the field in order to follow the related environmental researches

** reading the meaning of the evidence in the relationships to the project

* Level 2

** foreshadowing the expected outcomes of design decisions upon the general readings

** measuring the results through the analysis of the implications, the construction of a chain of logic connection from decision and future outcome, in order to reduce arbitrary decisions

* Level 3

** reporting the results publicly, writing or speaking about results, and moving in this way information beyond design team

** subjecting methods and results to others who may or may not agree with the findings

* Level 4

** publishing the findings in reviewed journals

** collaborating with academic or social scientists

== Related approaches ==

=== Working model for the application of EBD ===

The [http://www.healthdesign.org/hcleader/whitepapers.html ”White Paper (series 3/5)”] written by The Center for Health Design presents a working model that help designers to use and implement EBD decision-making practices.

As shown in figure , at the center of the model is the main goal that is providing a healing environment; positive outcomes achievement depends on three investments:

* designed infrastructure including the built environment and technology,

* reengineered clinical and administrative practices to maximize infrastructure investments

* transformational leadership to maximize the human capital and infrastructure investments

All three investments depend on existing research, and the investment results should contribute to the growing body of EBD approach.

=== {{anchor|Performance Based Building Design (PBBD)}}Performance-based building design===

=== Ten strategies for the implementation of EBD ===

EBD is closely related to [[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 [http://www.healthdesign.org/hcleader/whitepapers.html ”White Paper (series 3/5)”] written by The Center for Health Design identifies ten strategies to help decision making, according to EBD practices. They are specified below.

* 1. 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.

* 2. Use an integrated multidisciplinary approach with consistent senior involvement, ensuring that everyone with problem-solving tools is included. It is essential stimulate synergy between different community to maximize efforts, outcomes and interchanges.

* 3. Maintain a patient-and-family-centered approach: patient and family experience are key to define aims and to assess outcomes efficacy.

* 4. Focus on financial operating impacts, getting past the paralysis of first-cost, exploring the cost-effectiveness of design options over time and considering multiyear returns of investment.

* 5. Apply disciplined participation and criteria management. These processes uses decision-making tools such as SWOT analysis, analytic hierarchy processes, and decision trees that can also be used in design processes, particularly for critical technical aspects, such as structural, fire safety, or energy design.

* 6. Establish quantitative criteria linked to incentives in order to increase motivation of the team design through the definition of measurable outcomes and to involve end users through checklists, surveys, simulations.

* 7. Use strategic partnerships to accelerate innovation, in order to create innovative new products using hospital staff expertise and leverage.

* 8. Support and demand simulation and testing assuming the patient’s perspective through making lighting, energy, and other kinds of models; and computer visualizations.

* 9. Use a lifecycle perspective (30-50 years), from the strategic planning to the sustainment, especially to explore the lifecycle return on investment of design strategies as they impact safety and work-force outcomes.

* 10. Overcommunicate: positive outcomes are closely linked to the involvement of clinical staff and community members; it can be reached by attending meetings, sending out newsletters, creating Web cams, and other tools.

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===

== Tools ==

[[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.

Traditionally, evidence-based design has been applied for the measuring of the efficacy of a building design; it is usually carried out at the post-construction stage as a part of a [[Post-Occupancy Evaluation (POE)]]. POE evidences the effectiveness or the weaknesses of design decisions in relation to human behaviour in built environment. Usually questions concern issues such as acoustics, odor control, vibration, lighting, ser-friendliness, and so on, and are binary-choice (acceptable or not acceptable).

Other research techniques, such as direct observation, photography, checklists, interviews, direct surveys, focus groups are utilized to supplement traditional design research methods.

Several assessment tools are developed by [http://www.healthdesign.org The Center for Health Design]and by *[http://www.pickerinstitute.org The Picker Institute], to help healthcare managers and designers in gathering information on consumer's needs, assessing their satisfaction, measuring quality improvements. These tools are commonly used in EBD practices and can be downloaded by the CHD web site.

* '''Patient Environmental Checklist''' is addressed to patient and is useful to assess an existing facility's strong and weak points. Specific environment features are evaluated by patients and their families through a 5-point scale. Checklist quickly shows which areas need to be improved.

* '''Patient Survey'''’s purpose is to achieve information on patients' experiences with the built environment. Questions range is wide, since patients' priorities may be very different from those of administrators or designers.

* '''Focus Groups''' with consumers are oriented to learn more about their specific needs and generate ideas for future solutions.

=== {{anchor|Research-Informed Design}}Research-informed design===

== Recommendation for EBD ==

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.

The following are three macro-objectives related to the EBD approach and some related specific objectives analyzed in [http://www.healthdesign.org/hcleader/whitepapers.html ”White Paper (series 3/5)”] written by The Center for Health Design; for each are briefly explained some practical actions to achieve the goal.

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.

* '''OBJECTIVE 1: IMPROVING PATIENT SAFETY THROUGH ENVIRONMENTAL MEASURES'''

** 1.1 '''Reducing Hospital-Acquired Infections'''. Infection rates are lower when there is good air and water quality and physical separation. This correspond to the use of air quality control measures, to the choice of easy-to-clean floor, wall, and furniture coverings, and to the preference for single-bed rooms with private toilets to enable separation or isolation of patients.

** 1.2 '''Reducing Medical Errors'''. Several studies show that medical errors are not caused only by the mistakes of a few individuals, but often they are linked to environmental factors. For example, error rates increase when there is an interruption or distraction from an unexpected noise (a telephone call), and they decrease significantly when the lighting level for work surfaces is sufficiently high.

== {{anchor|Current state|Research centers|Accreditation and certification}}Research and accreditation==

* '''OBJECTIVE 2: IMPROVING PATIENT OUTCOMES THROUGH ENVIRONMENTAL MEASURES'''

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 | date=20 July 2010| author1=Apuccinelli | work=The Center for Health Design }}</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.

** 2.1 '''Reducing Pain'''. Scientific studies have shown that exposing patients to nature can produce significant alleviation of pain. Besides, other researches also suggest that patients experience less pain when exposed to high levels of daylight in their rooms. Finally, some research also supports displaying visual art with nature subject matter helps reducing pain.

** 2.2 '''Improving Patients’ Sleep'''. Sleep disruption and deprivation are common problems in healthcare buildings; increasing acoustic performance with reduced reverberation time increased sleep quality.

** 2.3 '''Reducing Patient Stress'''. Patient stress is a significant negative outcome in which bears many other healthcare negative consequences. A physical environment that contains stressful features makes psychological patient state worse. Several experimental studies have shown that real or simulated views of nature can produce restoration from psychological stress in few minutes. Other studies based on behavioural observation suggest that gardens in hospitals can reduce stress among patients and families. On the other hand, some studies suggest that many patients respond negatively to abstract art, causing stressful reactions. Besides, many researches has shown that noise is an important stressor.

** 2.4 '''Reducing Depression'''. Many studies show that exposure to bright artificial light and daylight is effective in improving mood and reducing depression, even for people affected by deep depression.

** 2.5 '''Reducing Spatial Disorientation'''. Wayfinding problems in hospitals have a significant impact both on patients and visitors, who can be stressed and disoriented. A large body of literature has explored how people find their way through hospitals and other complex buildings (i.e. Space Syntax Analysis). For example, complex layouts are difficult to find one’s way in, and some studies have found that right turns are easiest to maintain.

** 2.6 '''Improving Patient Privacy and Confidential'''ity. It is based on great evidence that the provision of single-bed rooms increases patient privacy. Furthermore, providing private discussion rooms near waiting, admission, and reception areas may help avoiding breaches of speech privacy.

** 2.7 '''Fostering Social Suppo'''rt. Some studies recommend the provision of stays and waiting rooms with comfortable furniture arranged in small cluster, in order to encourage social interactions. Carpets instead of vinyl for floors in patient rooms seem to increase the length of people’s stay.

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.

* '''OBJECTIVE 3. IMPROVING STAFF OUTCOMES THROUGH ENVIRONMENTAL MEASURES'''

** 3.1 '''Decreasing Staff Stress'''. Stress is the most common cause of staff retirement. Environmental stressors include noise, light, and multied-bed patient rooms. In fact, survey research shows that single-bed patient rooms are perceived to be less stressful for both family and staff than ones containting multi-beds.

** 3.2 '''Increasing Staff Effectivene'''ss. While most research IS aimed at patients, there is a growing body of evidence suggesting to improve hospital efficiency through making the jobs of staff easier. This can be achieved by spatial solution, environmental factors, technological devices.

== {{anchor|Evidence-Based Design Process}}Process ==

== Financial impact ==

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>

Hospitals’ chiefs and designers say that building a patient-oriented facility increases marginally the cost of construction, and the extra expense does not pass along to patients.

*Gather qualitative and quantitative intelligence

EBD practices, if applied to the whole healthcare system, maximize the capital investment by quantifiably improvements, producing a significant multiyear return on investment. In fact, cost savings resulting from reducing infections, decreasing staff turnover efforts, reducing hospitalization time, properly managed and monitored, match to financial benefits that continue for several years, making the innovations a long-term investment.

* Map strategic, cultural and research goals

*Hypothesize outcomes, innovate, and implement translational design

* Measure and share outcomes

=== Meta-analysis template for literature review ===

==External links==

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.

* [http://www.healthdesign.org The Center for Health Design]

* [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 that summarizes current evidence-based design research for healthcare.

A systematic review process should follow five steps:

* [http://www.informedesign.umn.edu/ InformeDesign] free online research database of studies linking the environment to outcomes.

# 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 [[SWOT analysis]], analytic hierarchy processes and [[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}}

* CAMACama, R., "Patient room advances and controversies: Are you in the evidence-based healthcare design game?", in ''Healthcare Design Magazine'', 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, in Health Facilities Management. July 2009

* 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

* Kirk, Hamilton D., "Research Informed Design & Outcomes for Healthcare" in ''Evidence Based Hospital Design Forum'', Washington, January 2009.

* KIRK HAMILTON D., Four Levels of Evidence-Based Practice, The AIA Journal of Architecture, November 2006

* STANKOSStankos, M., SCHWARZand 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.

* ULRICHUlrich, R.S., [https://www.brikbase.org/sites/default/files/Roger-Ulrich-WCDH2000.pdf "Effects of Healthcare Environmental Design on Medical Outcomes,"] in ''Design & Health–TheHealth – The therapeutic benefits of design, proceedings of the 2nd Annual International Congress on Design and Health,''. Karolinska Institute, Stockholm, June 2000.

* WEBSTERWebster, L., STEINKEand 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] {{Webarchive|url=https://web.archive.org/web/20170419154817/http://hcleader.healthdesign.org/whitepapers.html |date=2017-04-19 }}'', Center for Health Design, September 2008.

* SADLERUlrich, BR.LS., DUBOSEZimring, JC.RM., MALONEZhu, EX., Dubose, J., Seo, H.B., ZIMRINGChoi, CY.MS., TheQuan, businessX. caseand forJoseph, A., "A review of buildingthe betterresearch hospitalliterature throughon evidence based healthcare design", WHITEWhite PAPERPaper SERIESSeries 15/5, ''[http://hcleader.healthdesign.org/whitepapers.html Evidence-Based Design Resources for Healthcare Executives,] The{{Webarchive|url=https://web.archive.org/web/20170419154817/http://hcleader.healthdesign.org/whitepapers.html |date=2017-04-19 }}'', Center for Health Design, September 2008.

* ZIMRING C.M., AUGENBROE G.L., MALONE E.B., SADLER B.L., Implementing healthcare excellence: the vital role of the CEO in evidence based design, WHITE PAPER SERIES 3/5, Evidence-Based Design Resources for Healthcare Executives, The Center for Health Design, September 2008

* ULRICH R.S., ZIMRING C.M., ZHU X., DUBOSE J., SEO H.B., CHOI Y.S., QUAN X., JOSEPH A., A review of the research literature on evidence based healthcare design, WHITE PAPER SERIES 5/5, Evidence-Based Design Resources for Healthcare Executives, The Center for Health Design, September 2008

==Further reading==

* ''A Visual Reference to Evidence-Based Design'' by Jain Malkin [http://www.healthdesign.org/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 [http://www.healthdesign.org/edac/examstudyguide]''.php]

* ''[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 [http://www.healthdesign.org/resources/pubs/PractitionerGuide.php]

* ''Evidence-Based Design for Multiple Building Types'' by D. Kirk Hamilton (Author),and David H. Watkins (Author) [http://www.amazon.com/Evidence-Based-Design-Multiple-Building-Types/dp/0470129344/ref=sr_1_1?ie=UTF8&s=books&qid=1256432092&sr=8-1]

* 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.

* PAWSON R., Evidence-based Policy: a realistic perspective, Sage Publications Ltd, 2006

* 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.

* CHRIS E. STOUT,RANDY A. HAYES, The evidence-based practice: methods, models, and tools for mental health professionals, John Wiley and Sons, January 2005

* Cama, R., (2009). ''Evidence-Based Healthcare Design''. Hoboken, New Jersey: John Wiley & Sons, Inc.

* ULRICH R., QUAN X., ZIMRING C., JOSEPH A., CHOUDHARY R.,The Role of the Physical Environment in the Hospital of the 21st Century, report to The Center for Health Design, September 2004

* 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]

{{Evidence-based practice}}

{{Design}}

{{DEFAULTSORT:Evidence-Based Design}}

[[Category:HealthcareHealth care quality]]

[[Category:Decision theory-making]]

[[Category:MedicalHealth informatics]]

[[Category:HealthcareEvidence-based designpractices]]