How can designers create an atmosphere for the healthcare experience that best accommodates the needs of patients? What tools can designers use to make sure they are designing differently, and not repeating the same flaws present in previous healthcare designs? The answer lies in something called evidence-based design. Rosalyn Cama, FASID, defines evidence-based design as an iterative decision-making process that begins with the analysis of current best evidence from an organization as well as from the field. She further describes evidence-based design as a process that does not find prescriptive solutions, but is rather a platform from which to add an existing base of knowledge or to launch innovation. When aligned with a stated design objective, it will find behavioral, organizational, or economic clues that can be hypothesized as a beneficial outcome.

Evidence-based design is a method that requires a problem (new facility to be designed for its own individual purpose) first. A person who is implementing evidence-based design will follow a process similar to a science experiment. Cama separates the process of evidence-based design into four components: 1. gather qualitative and quantitative intelligence; 2. map strategic, cultural, and research goals; 3. hypothesize outcomes, innovate, and implement translational design; 4. measure and share outcomes. Cama states that it is important to gather intelligence throughout the entire process of design. It is usually in the programming phase that qualitative and quantitative information begins to shape a project, but Cama believes this is detrimental to the process because the information gathered is usually from what she refers to as “stale models,” or precedents that don’t do anything to aid in the innovation of the design task at hand. She believes that when implementing evidence-based design, investigations should be done even before programming to intelligently inform what the project goals and guidelines will be. This process allows the design team to get a better understanding of the existing culture of the organization, its strategic objectives, and discover whether it is capable of providing the client with the best solution that is already known in the industry, or if innovation is required to meet the needs of the particular client or project goals.

After the first stage or component is complete and the proper information or intelligence is inquired, the second step is to synthesize all of the collected data and transfer it into a project vision and map research goals. Cama believes that value-driven leadership is required in this stage to make sure that goals are not set solely to fulfil selfish desires. Mapping a project’s vision will require a certain skill that will define the project’s drivers and improved outcomes while positioning the project towards greatness, and most importantly establishing a research agenda. A research agenda is essentially an outline that lists what research is needed to achieve the goals of a project.

According to Cama, the third step or component is where the real reason for evidence-based design becomes apparent. Designers hypothesize outcomes, innovate, and then implement translational design. Cama believes that designers are trained to use intuitive approaches to design, basing their decisions on past successes or failures. The difference between a traditional design approach and evidence-based design is that the evidence-based approach does not rely on a single designer or individual’s internal subjective database of past success or failure, but rather on a constantly evolving database of many others’ successes and failures. This hypothetical database is ever-evolving because as more and more projects are created and designers prove or disprove other designers’ hypothesized outcomes, methods are constantly being reused and adapted or innovated to meet specific new project needs.

After all required data has been collected and analyzed, and project goals and guidelines are established with a research agenda, a design hypothesis is created, the entire team should be on board with clear direction for project success. It is at this point that a project designer or design team will strive to prove or disprove that a known outcome or proposed innovative outcome will work for the project.

The final and most important component in evidence-based design is the measuring of outcomes and sharing for the use of future researchers. Cama believes that the design industry has been slow to introduce new concepts because there is a lack of knowledge that is actually shared. Knowledge shared will inspire future design teams to develop concepts further, or to abandon a certain trend and move on. She adds that measured hypothesized outcomes can be done by groups of graduate students or research teams on staff with healthcare facilities (in the case of healthcare design). She believes it is important that outcome measurements are not done by someone employed by a design firm creating design to avoid bias.


According to Cama, reporting can be done at two different levels of scrutiny. One setting is the commonplace, in which design professionals network amongst peers in a conference-like atmosphere. Conferences may also be held with multidisciplinary audiences including, but not limited to architects, designers, hospital administrators, facility directors, and medical practitioners. The second method for reporting research is said to be a more desirable approach, and consists of submitting research for peer review to an Institutional Review Board (IRB). This method will engage academics to assist in the constructive criticism of the material and develop further arguments for or against the proposed design interventions (Zimring, Cama, 2009).

So why is evidence-based design important? According to Craig M. Zimring, PhD, there is a call from the public for significant and visible improvements in healthcare quality and safety. Groups such as the Institute for Healthcare Improvement have made very significant efforts to help to improve healthcare processes. Zimring, who is an environmental psychologist, has devoted his career to exploring how the built environment impacts individuals and organizations as a whole. In his work, he has explored whether there is actually convincing scientific evidence that the built environment plays a part in the quality of healthcare and patient, family, staff, and organization outcomes. During his research, Zimring believed the question at hand was one of urgency, as he claimed a variety of demographic, technical, competitive, and financial pressures, along with the confluence of healthcare insurance reform and the aging population have converged to create one of the largest healthcare building booms in U.S. history. He believed at the time of the conducted studies that the next decade would create hundreds of billions of dollars of new healthcare construction, which would shape U.S. healthcare for generations (Zimring, Cama, 2009).

When Zimring and his colleagues started the study, they realized that more scientific studies on the subject had been conducted than they had expected. They found many studies scattered amongst hundreds of journals touching on evidence-based research in multiple disciplines such as medicine, nursing, epidemiology, environmental psychology, and architecture. All of the information they found were studies in peer-reviewed journals, and a number were actually randomized field experiments in which clever researchers used natural experiments to determine conclusions like whether differences in qualities such as light or noise influenced pain, stress, or sleep.

Although at the end of their research they believed there was much more to be studied, they concluded there was convincing evidence that design could significantly impact outcomes. Some of those impacts they found were what they referred to as “direct impacts.” A direct impact is something like natural light and views reducing patient stress and the need for analgesic drugs. Other impacts include the way the built environment can support improvements in providing care; for example, Zimring claims that in a hospital, single rooms having multiple advantages like the reduction of infections, improved sleep, reduced necessity for moving patients due to roommate incompatibility, and reduced falls. This kind of evidence acquired has aided healthcare leaders and designers to create a new age of healthcare facility designs that will serve as tools for healthcare improvements.

Many organizations globally have already implemented the use of evidence-based design in their hospital projects. Some of these organizations include the military health system, which serves around 9.4 million people in 70 hospitals and 814 medical clinics worldwide. Other organizations include the Global Health and Safety Initiative, which represents 100,000 hospital beds is also using evidence-based design in order to increase patient, staff, and environmental safety. According to Zimring, one new evidence-based designed hospital, Ohio Health Dublin Methodist, had been open for nine months as of writing his piece in Cama’s book Evidence Based Healthcare Design and had yet to experience a single healthcare acquired infection.

Although there is growing evidence about the importance of the built environment for healthcare improvement, design practitioners have relatively little experience creating, judging, assembling, and using rigorous evidence. According to Zimring, academic disciplines like environmental psychology and studies relating to the built environment and behavior have been around since the 1960s, but only recently have design firms embraced these studies and findings and hired directors dedicated to creating, sharing, and using research. Cama believes that the strategy of evidence-based design is a shift and not a radical change for healthcare facility design. She claims that evidence-based design practice is the tool to be used in healthcare design and if a firm has not yet modified their design methodology to reflect and adopt the evidence based practice, then they are falling drastically behind (Zimring, Cama, 2009).





By Angelo Palmieri, M. Arch



Cama, Rosalyn. Evidence-Based Healthcare Design. Hoboken, NJ: John Wiley & Sons, 2009. Print.