Sustainability and Evidence-Based Design in the Healthcare Estate

Worldwide, healthcare organisations are facing challenges and demands to improve design quality and safety of their estate, while addressing burgeoning safety legislation and austere funding arrangements due to the 2007–2010 financial crisis and economic downturn. This has created an imperative for all providers, commissioners and regulators to address how the healthcare environment may need to change. Although widely acknowledged that healthcare guidance/standards and tools are essential to enhance quality and safety in health care, no studies have been published, nor indeed been carried out, with regard to their usefulness. By their very nature, studying guidance and tools is rarely an attractive subject for practitioners and academics alike. However, notable publications include sustainable healthcare architecture aimed at covering the twin big and complex subjects of sustainability and healthcare architecture (Guenther and Vittori: Sustainable healthcare architecture, 2007); a step-by-step guide of how to implement an evidence-based design (EBD) process and those seeking to learn the methodology for EBD of healthcare facilities (Cama: Evidence-based healthcare design, 2009); and a description of evidence-based healthcare facility design that is meant to support quality care and reduce costs (McCullough: Evidence-based healthcare design, 2009). Crucially, the lack of studies and consequently dearth of publications that focus on the role of technical guidance and tools is manifested by the absence of policies and appropriate strategies, as well as a rationale, not only for aiding decision-making in healthcare organisations, but also for acknowledging that, fundamentally, technologies, policies and services are subject to shorter life cycles than the relatively inflexible built assets that support them. This Springer Brief aims to increase our understanding of the role played by technical guidance/standards and tools in design, construction and operation of healthcare facilities as well as ultimately establishing the impact of the physical environment on staff and patient outcomes. Consequently, the aim is for the development of guidance and tools that will aid the creation of architectural environments of quality and safety, which will lead to positive patients’ health outcomes and improved staff productivity.

Identification and analysis of design strategies is essential for this brief to increase our knowledge and understanding in order to provide a rationale basis and underpin the joint approach to property and asset or infrastructure design and management. These are advocated as a way to address in the healthcare sector fragmentation, duplication, redundancy, unsustainable transportation and non-standardisation due to the creation of varying levels of accommodation standards. Design strategies are important because they can aid organisations determine what to produce and do (products or outcomes), how and when to do it (process) and how consistently innovative the products are and over time perform responding to changing contexts (performance) while delivering on return on investment. They can therefore play a vital integrating role in connecting design endeavours to organisation’s business strategy, in identifying the core business and focus of an organisation, in adopting the latest technologies, translating insights into actions and their prioritisation. A brief review of a selection of the main design approaches and strategies from the many that have been advocated for architectural healthcare design in recent times is conducted to provide a suitable basis for the development of technical guidance and tools. These include interrelated design for sustainability, evidence-based design, lean health care and lean-led design, six sigma, simulation modelling, learning from completed construction projects [post-project evaluations (PPE) and post-occupancy evaluations (POE)] and varying combinations of these. Identifying approaches towards measuring and monitoring the environmental impact of new buildings and refurbishment of existing buildings is essential to respond to how best projects in future minimise direct environmental effect. The underlying premise includes the use of different materials, how to manage resources optimally and lessons learnt from the most innovative methods which have been undertaken or applied to address these issues.

The development and update of healthcare premises planning information, technical guidance and tools in health care are controversial and have tended to engender a lot of debate. This is because many interrelated issues are involved, for example, stewardship (whether public or private), regulation (extent of compliance and associated penalties for non-compliance), rationale (whether prescription or performance based), quality, responsibilities and costs of development and updates to keep this information relevant and responsive to changing healthcare practice and technology. In recent years, there have also been many concerns over the ever-increasing amount of advice on best practice standards in the planning and design of healthcare facilities due to burgeoning safety legislation, raising expectations for quality and safety improvements and demands for effectiveness and to achieve value for money. The introduction of new procurement routes such as private finance initiative, public–private partnerships over and above the traditional one has added complexity. A summative rather than a comprehensive review of the healthcare planning information, healthcare facility briefing systems and tools provides an appropriate basis to evaluate some of the issues identified above. The review also answers the question of need for technical guidance and tools in healthcare over and above the planning regulation and building control applied to other types of the built environment. Traditional focus of building control has, in recent times, seen expanded state interventions in health and safety, including prevention of fire risk in buildings to application of rules, regulations and standards relating to the form and performance of buildings and the built environment. This has been necessary not only in order for building design to respond to increased threats to health and safety posed by terrorism and climate change but also to address sociopsychological and cultural issues related to place-making and sustainable urban living. As a result, there has been a proliferation of state-centred legal forms of regulation, formations and a plethora of rules, standards and governance practices as well as requirements by insurance companies to identify, prevent and contain risk (Imrie and Street 2011).

Through a number of carefully selected purpose-built Case Studies from the UK, EU, USA, China and Australasia, this section indicates how strategies that integrate sustainability and evidence-based design have been implemented in healthcare design practice. The aim is to document the key drivers for these case study projects and the consequences of applying these design approaches. In doing so, the brief seeks to increase our understanding of the relationship between theory and practice, thus uncovering mechanisms to embed sustainability and evidence-based design in working practices. Ultimately, this will improve efficiency and effectiveness in the delivery of positive healthcare outcomes.

This brief started by looking at the changing context for national and international healthcare systems, before reviewing the healthcare premises information, guidance and tools that underlie the approach in which sustainability is to be seen as integrated with evidence-based design rather than as divorced and separate themes. However, to understand the role these aspects play, it is also essential to consider both the historical context and, in particular, the organisational structures of the different healthcare systems whether these are national or international. This chapter discusses emerging issues from the approach that adopts design for sustainability integrated with evidence-based design. The aim is to help decision-making within the area of healthcare premises, planning and design whether this is nationally or globally. The crucial emerging issues start with the problem of definitions of ‘Evidence’ and ‘Sustainability’ but include the debates surrounding several themes: Centralisation versus Decentralisation, the nature of Public versus Private Sector Involvement, National versus International Standards to Prescription versus Performance Standards. Addressing these issues has an important bearing on the development of design for sustainability and evidence-based design as science.

To achieve success, providers, commissioners and regulators of the delivery of healthcare or more specifically the accommodation in which health and social care is provided need to proactively embrace the principles of design for sustainability integrated with evidence-based design. Also of importance is that the process involves users or occupants of the healthcare facilities. Otherwise, efforts to meet sustainability targets and aspirations for design quality improvement are futile without a meaningful engagement of users. This means that the imperative is for a cultural shift and raising awareness among the users and managers of healthcare facilities at both the local level of a clinic, the geographical health economy comprising hospitals, clinics and care homes, and the national healthcare system as well as globally. A culture change and increased awareness is also not enough but needs to be translated into actions by both individuals and organisations. Within the organisation, the support needs to emanate from the top down in order to be effective. Applying and implementing design for sustainability is perhaps the greatest challenge for any organisation that adopts and commits to this approach. The case studies in this brief highlight the different starting points and focus. In particular, the strategy in the UK has tended to be that of providing publicly sponsored and funded health care guidance and design tools to aid the design process compared with the US where the focus on practice has encouraged private firms to implement principles of sustainable evidence-based design.