Research Informed Design,Best Practice,and Fresh Perspectives: Can We All Get Along?

Research Informed Design

HERD has been a bully pulpit for advocacy of research informed design, or evidence-based design. The journal's editors and sponsoring organizations are on record as supporting the idea that better healthcare design decisions may be made by practitioners who refer to the scholarly literature and research findings in order to interpret their implications for a current design project.

It is difficult, if not impossible, to argue that the opportunity for a better design decision addressing an issue deemed important by the client should be missed. If interpretation of credible scientific evidence and carefully measured outcomes from completed projects can help produce better results, possibly including better clinical outcomes, there would seem to be a significant, even moral, obligation to utilize a rigorous, research informed design process for the current project.

When a highly regarded organization identifies reducing drug mixing errors as a key design issue for its proposed cancer center project, it might be helpful to turn to the literature to see what is known about the topic. An evidence-based practitioner might convert the design issue into researchable questions about drug mixing errors, environmental factors, and behavioral factors that could lead to relevant information that would influence development of design concepts intended to reduce errors. A better understanding of the role of interruptions, lighting, fresh air, and barcode technologies, as a few examples, could result in superior design decisions.

Although such committed advocacy for a research informed design process sounds unwavering, it does not mean that every possible project, or every decision on a project, deserves the same rigorous process. A rigorous, evidence-based design process is advisable for addressing one or two key design issues on a project for which there is little available information, or for which there is no obvious solution consensus. That same extra effort and possible time commitment may be unreasonable if extended to a large number of less important design decisions. Which means that the vast majority of decisions on a healthcare project will likely be made on the basis of accepted best practices.

Best Practice

Healthcare design has long been a specialty within the design field, based on the complexity of the clients' enterprise, and the extreme importance of life and safety for highly vulnerable populations. A number of design practitioners have developed a specialization in healthcare design, and practice at a high level of competence based on experience and continuous learning. These practitioners are using what the profession and the courts call best practice. They depend on detailed knowledge about the clients' requirements, and draw from a storehouse of relevant experience and local knowledge about the best way these issues have been addressed in the past.

Organizations like the American College of Healthcare Architects (ACHA) and the American Academy of Healthcare Interior Designers (AAHID) set minimum standards for individual board certification in the specialty of healthcare design, and verify qualifications through examination and review of a practitioner's experience. Other organizations such as the American Society for Healthcare Engineering (ASHE) and the Nursing Institute for Healthcare Design (NIHD) represent memberships with a focus on healthcare environments. There are widely read professional magazines and journals, like HERD, that are devoted to the specialty. There is a rich, cross-discipline culture associated with the healthcare design specialty that interacts on projects and through participation in professional societies, conferences, and continuing education.

The vast majority of design decisions for North American healthcare institutions are made by experienced design practitioners who have developed a track record of experience within the specialty of healthcare. Just as it is unlikely for a major high-rise developer to hire an architect that has never done a high rise, it is unlikely that an inexperienced architect would be engaged for a major, complex healthcare project. It is increasingly rare to hear of an architect who has never designed a hospital being engaged for a project because of, for example, a family relationship to the board chair. When an inexperienced firm must deliver a complicated healthcare project, it is normal to add an experienced employee, or to associate with an experienced firm.

It is difficult to imagine a successful result if someone with no experience were to be required to design and build a complex healthcare environment, such as a contemporary, state-of-the-art imaging center with the demands of technical equipment like biplane fluoroscopy, CT scanners, MRI machines weighing many tons, and a unique workflow based in digital images. Of course it might be possible, but there would likely be be complications, delays, revisions, and perhaps even poor budget control. Most likely, of course, is that an experienced practitioner would be invited to play an expert role on the team.

Fresh Perspectives

Some voices in the field have suggested that the body of contemporary healthcare architecture does not meet the highest standards of design. It is possible that they may be right, as so many hospitals and clinics are still bleak, institutional and confusing warrens, although much design work in the field has been quite strong in recent years. There is no doubt that the current inventory of healthcare facilities could be improved by some fresh thinking.

It has been suggested that healthcare design needs a new, outsider's perspective from skilled practitioners without an ingrained bias about the way things have been done in the past. There are calls to add outstanding non-healthcare designers to awards juries. Some have gone so far as to suggest that anyone associated with a long record of hospital design should be removed from consideration.

It should not be controversial to engage a skilled design practitioner with little healthcare experience to prepare the site plan, landscape plan, parking garage, entry, lobby, principal circulation patterns, gift shops, chapel, and food service aspects of a hospital project. None of these require an intimate knowledge of clinical practice or the complexities of medical gas distribution. In fact, designers drawing inspiration from experience having nothing to do with healthcare may bring wonderfully creative ideas to the project.

A hospital's departmental renovation that simply relocates some personnel and alters some walls, doors, and air conditioning ductwork would not seem to need a rigorous search of the literature. It would seem that it might be designed and implemented by best practice methods, or by designers not burdened by highly technical requirements for medical equipment or utilities.

No Place for Misguided Ego

If a designer lacking healthcare experience is carried away by a sense of self-importance and a tendency to serve individual ego rather than the client's best interest, problems could arise. When aspects of design can be random or subjective, there is a danger that a self-absorbed designer can make arbitrary decisions on the basis of personal preference, misunderstanding, or ignoring the project's fundamental requirements. Such decisions can reduce the effectiveness and operational performance of the project. Such projects can never fulfill their maximum potential contribution to the organizations and the communities they serve. A good designer working in a new area knows how and when to ask others for advice and explanatory background information.

Participatory Involvement of the Users

One important way to assure that the requirements of the organization and the users are met is to effectively involve them in the design process. Most experienced healthcare practitioners work with some form of a participatory process. I have always believed that while it is possible to design a healthcare facility independently, the result will always be better if the physicians, nurses, support staff, and executive leadership have a meaningful role in the decision making. This would appear to be true whether in a best practice or an evidence-based process, and even more important for an inexperienced designer or design team.

Collaboration

I believe there is a place for each decision-making model of practice in a successful project. I am convinced that each of these successful design processes can comfortably co-exist. Any complex healthcare project deserves an evidence-based approach for a certain number of key decisions. At the same time, serious healthcare projects deserve the focused expertise of best practice for the vast majority of the design decisions related to clinical practice, stringent code requirements, and complicated utility infrastructures. And yet, there must be room in projects for the innovation and creativity brought by fresh eyes, especially in areas that impact campus and circulation planning, public spaces, user experience, non-clinical settings, and the aesthetics of a design solution. This kind of collaboration is probably already occurring at some firms where these complementary skills and methods are being applied in concert, or on other projects where the teaming of firms provides a respectful mix of capabilities in service to the client.

Highest Value Found in a Cooperative Mix

It is time for advocates of these different perspectives to admit that there is real value for clients in each model. It is plausible that clients can best benefit from the judicious application of each distinct way of designing healthcare projects, and potentially from a combination of models, depending on the individual, unique project requirements. Architecture, engineering, and design must serve healthcare clients with the best combination of experienced best practice decision making, supported by research informed design for critical issues, and fresh, new ideas from creative minds willing to look elsewhere for inspiration. Design practitioners with skills in these areas must work together with collaborative, supportive respect to deliver the best results.