‘Rigor and Research in Healthcare Design: A Decade of Advocacy’: Evidence, Decisions, Guidelines, and Standards

Kirk Hamilton

The McMorrow Reports is excited to bring you the second of four bi-monthly excerpts from the industry-acclaimed Evidence-Based Design resource book Rigor and Research in Healthcare Design: A Decade of Advocacy.

The book was written by Kirk Hamilton, FAIA, FACHA. Hamilton is a Professor of Architecture, Texas A&M University, a Founding Principal of WHR Architects and a board member of The Center for Health Design. He is also an editor of Health Environments Research & Design Journal. Hamilton has published more than 30 articles, many of which are featured in the book, on Evidence-Based Design (EBD) in HERD and Healthcare Design magazine.

Herman Miller Healthcare, working in collaboration with Hamilton and Vendome Group compiled many of the architect’s writings into this single, printed publication.

If you are attending the Healthcare Design Conference in San Diego, you can meet Hamilton on Nov. 17. He will be signing his book starting at 11 a.m. in the Herman Miller Booth (#1001). The books are free of charge and are courtesy of Herman Miller Healthcare and Nemschoff.

Coming in the next few weeks: Ten Suggestions for Increasing Rigor in Architecture & Design; and Flexibility, Differential Obsolescence, and Measurement.

Excerpted from Chapter 7: Evidence, Decisions, Guidelines, and Standards

The evidence in every field—especially in medicine—is constantly evolving and growing, so rigid standards based on findings that can easily be superseded are  likely to be inappropriate. The evidence from environment-behavior studies and many types of social science research in complex, multivariable settings is often less  conclusive than the quantitative studies one associates with medicine and the  hard sciences. Evidence applied to one situation may produce a completely different recommendation in another situation.

These factors weigh against premature conclusions and therefore against restricting design professionals and their clients with guidelines, standards, or codes based on limited information. For this reason, the board of The Center for Health Design has in the past been reluctant to issue design guidelines that could be interpreted  as exhaustive, or the entire answer, when they might have been written only as a start to encourage further development of evidence-based design principles….

A checklist may be the lowest level of recommendation. I tend to think of guidelines as nonbinding recommendations, somewhat more extensive than a checklist, perhaps with annotations that justify each recommendation. The credibility  of guidelines is in direct proportion to the credibility of the organization that  promulgated them. Guidelines from the Joint Commission or the American Academy of Pediatrics might be highly credible. Guidelines from AARP magazine, on the other hand, might be superb but less  credible to a professional audience. I see standards as voluntary recommendations that may or may not be compulsory, but created on the basis of careful research and testing. A standard, it would seem, carries more weight than a guideline. Building codes, of course, are regulations that have the force of law. Many regulatory  codes refer to standards, thus making the  standard into a de facto code or regulation…….

Guiding principles seem to be the province of a specific client or design firm, meaning that these principles were deliberately chosen to guide an identifiable body of work. The Planetree organization, for example, insists that all its facilities be  designed around patient-centered principles (Frampton, Gilpin, & Charmel, 2003).

Standards must be based on specific testing to confirm performance, and this testing must be performed by an organization with the appropriate expertise and an independent position. Finally, codes and regulations must be adopted only when the evidence is deemed to be conclusive, and when the public safety requires legal protection……

Performance-based standards vs prescriptive standards

Many in the design profession advocate performance-based standards versus the more prevalent prescriptive standards. A prescriptive standard says something like:  “Evidence shows that patients benefit from sunlight, views of nature, and exposure to the diurnal cycle; therefore the glass area in patient room windows shall be no less than 15 square feet.” Yes, the research is solid on these issues, but is the prescription correct? How big should the window be? Should it be different on the north and south faces? Should it be different in northern Canada and southern Florida? How many clients will choose a window larger than the minimum standard if it is likely to cost more?

A performance standard, on the other hand says something like: “Each patient room  shall receive 100-foot candles of natural light at noon on a typical December 21st.”

In this case, the north-facing windows may be quite different from the south-facing  ones. A performance standard describes a measure of desired performance and the  design team is given the flexibility to arrive at a result in any way it chooses.

The Quality of Our Decisions…

… ultimately, is what it’s all about.  Lehrer (2009) tells us that we need to carefully observe our decision making and use the full power of both our rational and emotional capabilities. He suggests we use our rational brain for the simpler or novel problems that require reason. The rational brain has difficulty confronting too many variables.

The emotional brain is especially useful at helping us make hard decisions. Its massive computational power—its ability to process millions of bits of data in parallel—ensures that you can analyze all the relevant information when assessing alternatives. (Lehrer, 2009, p. 248)

Designers may not be aware of the frequency with which they access their emotional brains, applying deeply held values to bolster their judgment in the face of complexity. They are acutely aware of any infringement on their freedom to make  design decisions; therefore they often resist imposed regulations. Because of this strong desire to preserve freedom to design, I don’t think the community of healthcare design professionals is ready for rigid or restrictive prescriptive standards; we may never be.

But we may have reached the time to embrace helpful recommendations, checklists, preliminary guidelines, and simple performance standards.

My intuition tells me there may be many times when well-considered guidelines could improve the quality of healthcare design projects. It may be time for interested parties to explore the idea of guidelines. …

“Rigor and Research in Healthcare Design: A Decade of Advocacy” is available for healthcare leaders, architecture and design professionals, as well as college students enrolled in healthcare design programs only through Herman Miller. You can request a copy of the book by contacting Anne Parks via email: anne_parks@hermanmiller.com