Contract - Designing for Health: What's Your Problem? A Research Approach to Quantifying Design Solutions

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Designing for Health: What's Your Problem? A Research Approach to Quantifying Design Solutions

23 May, 2011

-By Diana Davis, AIA, Perkins+Will, and Bowman O. Davis, Jr., Ph.D., Kennesaw State University


"Designing for Health" is a monthly, Web-exclusive series from healthcare interior design leaders at Perkins+Will that focuses on the issues, trends, challenges, and research involved in crafting today's healing environment.

The design process is a method of problem solving, though it is rarely considered in those terms. The nature of design investigation—the positing of questions and the application of responses to seek the best overall solution—lends itself surprisingly well to testing by the scientific method. Defined as the application of researched-based, quantifiable metrics to design decisions, the term “Evidence Based Design” (EBD) is used to establish a dialogue around the results of design inquiry. EBD is applied most often to healthcare projects because of the conceptual synergy with Evidence Based Medicine. Dr. David Sackett, a pioneer in evidence-based medical practice, describes it as "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of the individual patient…integrating individual clinical expertise with the best available external clinical evidence from systematic research."1 Applying the principles of scientific method to the questions most designers can easily articulate results in a process for translating design inquiry into a quantifiable research study.

To illustrate the research design process, a published EBD study by an interdisciplinary team of architect, medical director, researcher, and nurse will be referenced.2,3 Perkins+Will and Cabell Huntington Hospital replaced an existing multi-patient, open bay facility with a new, single family room, neonatal intensive care unit (NICU). Both client and designer were interested in the efficacy of the private room design on patient medical progress as well as on parent and NICU staff acceptance.

The first step in resolving either a design problem or scientific problem is to determine its subjective or objective nature. When thinking about issues addressed by the design, it is useful to consider the most basic goals of the project and attempt to pose them as questions. Objective questions lend themselves to quantifiable answers and data collection for resolution. Other seemingly subjective questions can still be addressed with quantifiable tools, such as survey questionnaires.

Once a problem has been identified and a literature search for other similar studies undertaken, a hypothesis can be developed. A hypothesis is not a question, but a statement that defines the parameters to be proven or disproven by testing. Hypotheses are similar to what designers refer to as a parti. There are many options for a design solution that could support a given parti, but one will be chosen for its sufficiency to balance the requirements of the project. Similarly, in developing an EBD investigation, there may be several scenarios that could be constructed for testing a hypothesis, but one should emerge as the best case.

In the referenced study, two hypotheses resulted in two study designs, one subjective and one objective. The first hypothesis was that parents of neonates would prefer a private room environment, but healthcare staff would not. Based purely on subjects’ perceptions of their environment, this hypothesis required survey questionnaires for quantification. The second hypothesis was that neonates would progress developmentally toward discharge more quickly in private rooms. Having secured prior approval for research with human subjects, the investigators could use clinical progress metrics to collect data for analysis.

In a subjective study, the primary problem is one of selecting survey questions yielding valid answers. Any survey should be “validity tested” to ensure that there is little chance of poor phrasing yielding ambiguous results. In an objective study, in which data are being collected about a patient population in a healthcare setting, early study design is critical. To prevent tremendous variability in the resultant data, it is advisable to narrow the focus to a sub-set of subjects that best represents the design intervention in question. An illustrative example is seen in the neonate subject population. Babies enter a NICU with a variety of clinical diagnoses and likely outcomes. Sadly, a fraction of that vulnerable patient population is too critically ill to respond to intervention. Other NICU admissions require only short-term observation before being discharged and are on the unit for too little time to benefit from any design modifications. For these reasons, the admitting neonatologist agreed to triage the study patients into five subgroups according to illness severity.4 Limiting the comparison of patient progress only to the middle-ranking subgroups provided statistically comparable test and control populations.

Unlike traditional laboratory research in which an experiment may, and should, be repeated, studies of the built environment often are limited by time and resources to a single opportunity. Without pilot studies or replicate observations common to laboratory experiments, it is advisable to err on the side of more data collection than less. Recording all possible data regarding physical environmental parameters and study population demographics insures that information, seemingly insignificant at the outset, will be available if needed. Information regarding prior clinical experience proved critical in interpreting data from caregivers in the Cabell NICU study. A serendipitous correlation between facility preference and clinical role was seen with healthcare staff,1 which would have been impossible to determine retrospectively given the anonymous nature of the survey.

When using subjective study questionnaires, it is important to control for naïveté among study participants, who may have experience with only one facility design and may be inherently biased for or against a given built environment. It is also tempting, when interpreting the results of study data, to draw conclusions of causality. With objective studies involving human subjects and great variability, the outcomes could result from any one of the changed variables, or some combination. Therefore, it is important to report only results verified by collected data without assigning highly speculative causal relationships.

The design and execution of a research study requires significant resources and time, both for designers and their clients. Given the subjective nature of the design process and the multivariate nature of human subjects and built environments, considerable care and creativity must be employed in constructing design studies. Creativity need not be limited to the realm of aesthetics, but can be practiced in the construction of research studies as well. Contributing valid, creative studies to the available literature both adds credence to the EBD process and documents the benefits of professional intervention in the spaces that structure much of our lives.

Diana Davis, AIA, is an architect and healthcare planner in the Atlanta office of Perkins+Will, specializing in the design of critical care units, surgery centers, and clinical laboratories. Diana.Davis@perkinswill.com

Bowman O. Davis, Jr., Ph.D., is an independent research consultant and professor emeritus of Biology at Kennesaw State University in Kennesaw, Georgia. bodavis@kennesaw.edu

SOURCES/CITATIONS:

1 Sackett, D.; Rosenberg, W.; Gray, J.; Haynes, R.; and Richardson, W., “Evidence-based Medicine - What it is and what it isn't”. BMJ 1996; 312:71-72. http://www.bmj.com/cgi/content/full/312/7023/71

2 Domanico, R.; Davis, D.; Coleman, F.; and Davis, Jr., B., “Documenting the NICU design dilemma: parent and staff perceptions of open ward versus single family rooms.” Journal of Perinatology advance online publication. 14 January 2010, 1-9.
http://www.nature.com/jp/journal/v30/n5/full/jp2009195a.html

3 Domanico, R.; Davis, D.; Coleman, F.; and Davis, Jr., B.O., “Documenting the NICU design dilemma: comparative patient progress in open-ward and single family room units.” Journal of Perinatology advance online publication. 11 November 2010, 1-8.
http://www.nature.com/jp/journal/vaop/ncurrent/abs/jp2010120a.html

4 Gray, J.; Richardson, D.; McCormick, M.; Workman-Daniels, K.; and Goldman, D., “Neonatal therapeutic intervention scoring system: a therapy based severity-of-illness index”. Pediatrics. 1992, 90(4), 561-567.

Past installments of "Designing for Health" include (click on title to access the full article):
 

Branding Food for Healthcare Facilities
Pre- and Post-Occupancy Surveys Influencing Design
Perkins+Will Research Journal—Integration of Design and Research within a Global Practice
The Role of Designers in Helping with Infection Control in Hospital Environments






Designing for Health: What's Your Problem? A Research Approach to Quantifying Design Solutions

23 May, 2011


"Designing for Health" is a monthly, Web-exclusive series from healthcare interior design leaders at Perkins+Will that focuses on the issues, trends, challenges, and research involved in crafting today's healing environment.

The design process is a method of problem solving, though it is rarely considered in those terms. The nature of design investigation—the positing of questions and the application of responses to seek the best overall solution—lends itself surprisingly well to testing by the scientific method. Defined as the application of researched-based, quantifiable metrics to design decisions, the term “Evidence Based Design” (EBD) is used to establish a dialogue around the results of design inquiry. EBD is applied most often to healthcare projects because of the conceptual synergy with Evidence Based Medicine. Dr. David Sackett, a pioneer in evidence-based medical practice, describes it as "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of the individual patient…integrating individual clinical expertise with the best available external clinical evidence from systematic research."1 Applying the principles of scientific method to the questions most designers can easily articulate results in a process for translating design inquiry into a quantifiable research study.

To illustrate the research design process, a published EBD study by an interdisciplinary team of architect, medical director, researcher, and nurse will be referenced.2,3 Perkins+Will and Cabell Huntington Hospital replaced an existing multi-patient, open bay facility with a new, single family room, neonatal intensive care unit (NICU). Both client and designer were interested in the efficacy of the private room design on patient medical progress as well as on parent and NICU staff acceptance.

The first step in resolving either a design problem or scientific problem is to determine its subjective or objective nature. When thinking about issues addressed by the design, it is useful to consider the most basic goals of the project and attempt to pose them as questions. Objective questions lend themselves to quantifiable answers and data collection for resolution. Other seemingly subjective questions can still be addressed with quantifiable tools, such as survey questionnaires.

Once a problem has been identified and a literature search for other similar studies undertaken, a hypothesis can be developed. A hypothesis is not a question, but a statement that defines the parameters to be proven or disproven by testing. Hypotheses are similar to what designers refer to as a parti. There are many options for a design solution that could support a given parti, but one will be chosen for its sufficiency to balance the requirements of the project. Similarly, in developing an EBD investigation, there may be several scenarios that could be constructed for testing a hypothesis, but one should emerge as the best case.

In the referenced study, two hypotheses resulted in two study designs, one subjective and one objective. The first hypothesis was that parents of neonates would prefer a private room environment, but healthcare staff would not. Based purely on subjects’ perceptions of their environment, this hypothesis required survey questionnaires for quantification. The second hypothesis was that neonates would progress developmentally toward discharge more quickly in private rooms. Having secured prior approval for research with human subjects, the investigators could use clinical progress metrics to collect data for analysis.

In a subjective study, the primary problem is one of selecting survey questions yielding valid answers. Any survey should be “validity tested” to ensure that there is little chance of poor phrasing yielding ambiguous results. In an objective study, in which data are being collected about a patient population in a healthcare setting, early study design is critical. To prevent tremendous variability in the resultant data, it is advisable to narrow the focus to a sub-set of subjects that best represents the design intervention in question. An illustrative example is seen in the neonate subject population. Babies enter a NICU with a variety of clinical diagnoses and likely outcomes. Sadly, a fraction of that vulnerable patient population is too critically ill to respond to intervention. Other NICU admissions require only short-term observation before being discharged and are on the unit for too little time to benefit from any design modifications. For these reasons, the admitting neonatologist agreed to triage the study patients into five subgroups according to illness severity.4 Limiting the comparison of patient progress only to the middle-ranking subgroups provided statistically comparable test and control populations.

Unlike traditional laboratory research in which an experiment may, and should, be repeated, studies of the built environment often are limited by time and resources to a single opportunity. Without pilot studies or replicate observations common to laboratory experiments, it is advisable to err on the side of more data collection than less. Recording all possible data regarding physical environmental parameters and study population demographics insures that information, seemingly insignificant at the outset, will be available if needed. Information regarding prior clinical experience proved critical in interpreting data from caregivers in the Cabell NICU study. A serendipitous correlation between facility preference and clinical role was seen with healthcare staff,1 which would have been impossible to determine retrospectively given the anonymous nature of the survey.

When using subjective study questionnaires, it is important to control for naïveté among study participants, who may have experience with only one facility design and may be inherently biased for or against a given built environment. It is also tempting, when interpreting the results of study data, to draw conclusions of causality. With objective studies involving human subjects and great variability, the outcomes could result from any one of the changed variables, or some combination. Therefore, it is important to report only results verified by collected data without assigning highly speculative causal relationships.

The design and execution of a research study requires significant resources and time, both for designers and their clients. Given the subjective nature of the design process and the multivariate nature of human subjects and built environments, considerable care and creativity must be employed in constructing design studies. Creativity need not be limited to the realm of aesthetics, but can be practiced in the construction of research studies as well. Contributing valid, creative studies to the available literature both adds credence to the EBD process and documents the benefits of professional intervention in the spaces that structure much of our lives.

Diana Davis, AIA, is an architect and healthcare planner in the Atlanta office of Perkins+Will, specializing in the design of critical care units, surgery centers, and clinical laboratories. Diana.Davis@perkinswill.com

Bowman O. Davis, Jr., Ph.D., is an independent research consultant and professor emeritus of Biology at Kennesaw State University in Kennesaw, Georgia. bodavis@kennesaw.edu

SOURCES/CITATIONS:

1 Sackett, D.; Rosenberg, W.; Gray, J.; Haynes, R.; and Richardson, W., “Evidence-based Medicine - What it is and what it isn't”. BMJ 1996; 312:71-72. http://www.bmj.com/cgi/content/full/312/7023/71

2 Domanico, R.; Davis, D.; Coleman, F.; and Davis, Jr., B., “Documenting the NICU design dilemma: parent and staff perceptions of open ward versus single family rooms.” Journal of Perinatology advance online publication. 14 January 2010, 1-9.
http://www.nature.com/jp/journal/v30/n5/full/jp2009195a.html

3 Domanico, R.; Davis, D.; Coleman, F.; and Davis, Jr., B.O., “Documenting the NICU design dilemma: comparative patient progress in open-ward and single family room units.” Journal of Perinatology advance online publication. 11 November 2010, 1-8.
http://www.nature.com/jp/journal/vaop/ncurrent/abs/jp2010120a.html

4 Gray, J.; Richardson, D.; McCormick, M.; Workman-Daniels, K.; and Goldman, D., “Neonatal therapeutic intervention scoring system: a therapy based severity-of-illness index”. Pediatrics. 1992, 90(4), 561-567.

Past installments of "Designing for Health" include (click on title to access the full article):
 

Branding Food for Healthcare Facilities
Pre- and Post-Occupancy Surveys Influencing Design
Perkins+Will Research Journal—Integration of Design and Research within a Global Practice
The Role of Designers in Helping with Infection Control in Hospital Environments



 


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