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The Evidence-Based Design Literature Review and Its Potential Implications for Capital Budgeting of

Glenn Ballard, MBA, PhD, University of California, Berkeley
Zofia Rybkowski, MS, University of California, Berkeley

Techniques for assessing literature reviews can assist in the evaluation of evidence-based design recommendations even before they are adopted into standards or codified into laws.

Evidence-based design (EBD) enhances therapeutic outcomes by producing design recommendations based on causal relationships between features of the designed healthcare environment (acuity-adaptable hospital rooms and spatial layout, for instance) and desired outcomes like reduction in patient falls and improved staff productivity.  EBD has the potential for improving the quality of care patients receive while supporting positive financial outcomes for health care organizations.

However, decision makers trying to incorporate the most fiscally responsible and patient-responsive EBD recommendations into their plans for new hospitals are confronted by significant obstacles.  Although assertions by EBD proponents about such issues as the impact of noise pollution, length of stay, family interactions, medication errors, and hospital-acquired infections make intuitive sense, claims about cost vs. benefit may be based on anecdotal, rather than objective, measures.  Time-sensitive requirements for facility development conflict with the ponderous process by which design standards are adopted.  This means that decision makers are often compelled to evaluate the evidence behind EBD recommendations that are not yet in the law or even in peer-reviewed literature and that may not be in current design standards.  Even though miscalculations can endanger the very survival of a healthcare organization, facility decision makers must forecast the benefits of alternative investments even though the available evidence does not support precise forecasting.

One important tool available to decision makers trying to assess the validity of EBD claims is the medical literature review.  The EBD research community employs various forms of these reviews to consolidate and analyze the results of individual studies.  To assist in the difficult process of evaluating claims about the impact of design options, the authors assess the construction and scientific rigor of each form of review.

Traditional literature reviews
Currently the most common form of review, traditional medical literature reviews are commissioned by journal editors and written by recognized experts.  Unfortunately, research indicates that when the results of such literature reviews on the same topic by different authors are compared, correlation is quite low.  Consequently, Ballard and Rybkowski suggest that decision makers view critically any recommendations made in these traditional reviews and considered them to be somewhat risky.

Systematic literature reviews
In the field of EBD, researchers are already moving beyond traditional literature reviews and compiling evidence using techniques required for systematic reviews.  In a systematic review, articles are generally listed in a table and scored according to the reviewers’ evaluation of the underlying research.  Scored reviews may examine multiple causal relationships between features of the designed environment and desired outcomes.  The more that evidence is supported by rigorous experimentation (such as randomized controlled trials), the lower the risk and the more confident decision makers can be about future results.  Many management decisions, however, are not amenable to a randomized controlled trial."

Meta-analyses
The meta-analysis is the most quantitative—and rigorous—of the review typologies.  Meta-analyses examine a single causal relationship between a feature of the designed environment and the desired outcomes, combining results from homogeneous randomized controlled trials.  By combining results from a number of trials, the reviewer is able to achieve a higher level of confidence about the cause-effect relationship being examined.  Compiling a solid meta-analysis requires the agreement of researchers worldwide on a common template for reporting results, so those results can be combined and analyzed.  Although not flawless, the meta-analysis is considered the most reliable type of literature review and is a reliable source of information for decision makers.

Ballard and Rybkowski note that, at this point in the development of EBD, quantitative studies are relatively rare.  However, following the historical development of evidence-based medicine (EBM), the authors expect quantitative studies to become more frequent.  This will result in more accurate estimates of the relative values of alternative investments, enabling capital budgeting for healthcare facilities that looks beyond capital cost to the impact of facility investments on running costs (such as staff requirements, productivity and retention; energy consumption, environmental sustainability, and maintenance) and patient outcomes (including waiting times, recovery times, satisfaction, and safety).

The authors note that Dave Chambers, chief architect of Sutter Health, recommends that the scope of EBD be reconceived to extend beyond “patient-in-the-bed” to include all desired outcomes of facility design.  They also offer a list of their own recommendations:

  • EBD primary researchers should employ quantitative methods of testing and evaluation where feasible.

  • EBD primary researchers focused on therapeutic outcomes should ally themselves with the EBM movement and its organizations, embracing EBM’s methodological standards and protocols.  Alternatively, an organization should be created to perform for EBD the functions that the Cochrane Collaboration or the Agency for Healthcare Research and Quality Evidence-Based Practice Centers Program performs for EBM.

  • EBD academic reviewers should employ systematic reviews, revealing inclusion and evaluation criteria.

  • Facility decision makers and their advisors should prepare themselves to evaluate the evidence behind EBD claims.

  • Facility decision makers and their advisors should collaborate with academic researchers to develop methods for capital budgeting of healthcare facilities that are sufficiently robust to accommodate EBD evidence ranging from the qualitative to the quantitative.

  • Facility decision makers and their advisors should fully incorporate sound EBD recommendations into capital budgeting of healthcare facilities.

  • EBD researchers and funding organizations should develop a shared understanding of the research frontier, methodological requirements, and a strategy for creating new knowledge.

  • An EBD research colloquium should be initiated to develop and implement these recommendations.

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