Healthy Measures

Text Douglas Macleod

Photos Peter Sellar

Architects are the last alchemists. With sleight of hand and rule of thumb, we conjure magical golden buildings from the base materials of wood studs and drywall. But what do we really know about what works and what doesn’t?

A few years ago Marco Polo, the former editor of Canadian Architect, remarked that when he was working as an architect for Montgomery Sisam Architects Inc. and designing seniors’ housing, staff at these facilities told him that they were able to reduce their patients’ medications when they were moved into their new facilities. In other words, good design could save Canada’s health care system millions of dollars every year. To me this is headline news, but because it is anecdotal those savings may never be realized–until now.

Some architects are pioneering the idea of evidence-based design as a means of rigourously examining past buildings in order to build better new ones. Evidence-based design borrows from work done in evidence-based medicine to carefully observe, quantify and analyze the way people use buildings.

One of the leading practitioners of this new approach is Farrow Partnership Architects Inc. of Toronto. As Tye Farrow puts it, “At the end of the day we need more tools to build the case for extremely well-designed buildings.” His firm is currently using evidence-based design techniques on a number of their current health care projects within the office–most notably the Carlo Fidani Peel Regional Cancer Centre in the Credit Valley Hospital where evidence-based design will be used to fine tune the current design and also be transferred to future projects at the hospital.

Credit Valley Hospital, Farrow Partnership and Workflow Integrity Network (WIN) formed a team and were awarded a $100,000 research grant from the Ontario Health Association Change Foundation and another $100,000 in an in-kind contribution of labour. The research team was able to measure, evaluate and learn from the performance of a similar facility, in this case another clinic at the Grand River Hospital.

A rigourous methodology is critical to Evidence-Based Design (or EBD). Only by carefully setting up the data collection can it be determined if the architecture really is affecting the health of the patient–rather than some related but less obvious factor. To this end, Karen Parent, Assistant Professor in the Faculty of Physical Medicine and Rehabilitation at Queen’s University and the President and CEO of WIN, was a key member of the research team. She and her team at WIN set up the framework in which the research could occur and in which valid data could be collected.

From her point of view, the purpose of this work “was not just about a return on investment in terms of reduced absenteeism and improved patient safety, but to gather baseline information to improve the design and its architecture.” In other words, the data was collected to inform rather than justify and the intent was to fully appreciate the facility in the context of its staff and its patients.

In some ways the design team was very fortunate in its choice of subjects, since according to Sean Stanwick, Project Manager with the Farrow Partnership, “the team was able to observe 10 nurses and approximately 60 patients in the old facility and will be able to observe the same patients and nurses when the new facility opens.”

Parent’s team would observe the patients and staff from a distance and (as unobtrusively as possible) enter their observations into their hand-held Palm Pilots. These Palm Pilots were pre-programmed with a variety of daily activities that would occur in the clinic and the observers would select the activities as they occurred and enter pertinent data such as travel time and contacts. As Stanwick observes, “They were essentially building a database of inputs and outputs.”

The hope is that this collection of inputs and outputs will lead to various design improvements in health care facilities. For example, previous studies have shown that nurses spend almost 30% of their time walking. If facilities were arranged more efficiently, they would have more time to spend with patients.

But there are numerous other benefits as well. When listing the potential advantages of gathering this data, Farrow includes: reduced length of stays for patients, better and more efficient workflows for staff, fewer errors and increased satisfaction. Even the size and positioning of the millwork, he points out, can be designed to improve the workflows.

Details are important and the intent is that the data collected should help the design team create better spaces for both patients and staff. As Parent observes, this could include even decisions about the placement of chairs in the treatment areas–should they be placed further apart to facilitate circulation or closer together to encourage dialogue between patients?

Of course, as Stanwick points out, “While the data gathered is specific to a particular facility, the biggest impact occurs when you can take the trends pulled out of the analysis and use it on other projects.”

In fact, the Credit Valley Hospital is only the tip of the iceberg. A number of other studies have been conducted using evidence-based design that demonstrate what a profound effect our buildings can have on our well-being. A study on daylighting in schools conducted in 1999 by George Loisis in California found that “students with the most daylighting in their classrooms progressed 20% faster on math tests and 26% on reading tests in one year than those with the least. Similarly, students in classrooms with the largest window areas were found to progress 15% faster in math and 23% faster in reading than those with the least.” These percentages are so large that I must admit I find them difficult to believe given that educators have laboured for years to find ways to improve learning skills by even small percentage points.

Another study undertaken by the Policy and Planning, Branch Planning and Information Services of Alberta Education in 1992 entitled “A Study into the Effects of Light on Children of Elementary School Age” found that “the effect on children of receiving trace amounts of UV radiation in their classrooms amounted to 1.75 fewer caries (cavities) per child per year than was the case in the non-UV schools.” And that “children exposed to high-pressure sodium vapour lighting were absent 3.2 days per year more than students under full-spectrum and full-spectrum with UV enhancement.” Translated into economic terms, this study calculated that if these benefits could be extended to all students in Alberta, the net savings would be $125,000,000!

But it gets even more astounding. Fred Gage at the Salk Institute in La Jolla California found that placing mice in more stimulating environments with a variety of stimuli ranging from other mice to toys to different foods actually led to the growth of new brain cells even in adult animals–which was long thought to be impossible. These new cells occurred in that part of the brain, the hippocampus, which is attacked by Alzheimer’s disease in humans. If, and it is a big if, the same were true in humans, it could save billions of dollars in health care not to mention the fact that it could combat the human tragedy of that disease. This may even be the explanation for Polo’s anecdote about their facilities and their effect on patient medication.

Perhaps what is most surprising, and disappointing, is that this is old news. Some of the studies discussed here are over 10 years old and Gage was repeating work that was first done in the 1960s (albeit with more detailed exploratory tools). Why hasn’t this work caused shockwaves in the world of design? Why aren’t architects at the forefront of this research? If any of these results are even marginally true, then it means that architecture is an essential element in our mental and physical well-being and evidence-based design is critical to not only proving that c
laim but also to enhancing the relevance and stature of the profession.

Part of the reason is that architects, like many professionals, do resist change and there are those who have legitimate doubts about this approach. Will it reduce our creativity? Will it erode our dwindling authority and control over designs? Will clients be willing to accept the additional costs of the approach? Will it increase our liability when the evidence shows that mistakes were made?

Farrow feels that the opposite is true. “Evidence- based design,” he states, “is a form of empowerment for architects because the context in which we make decisions becomes better informed and the design solution becomes much richer, more robust and more defendable. I see it as a competitive advantage.”

How other architects react to this advantage remains to be seen. For centuries, we have proceeded according to intuition and our approach to design is often based on our subjective and qualitative experiences but evidence-based design questions those assumptions, and how we integrate this technique into our practice could have enormous implications for the profession and for society in general.

Douglas MacLeod is a registered architect and the Associate Director of Research and Knowledge Mobilization at the Canadian Council on Learning. His e-mail address is [email protected]

For additional information on evidence-based design please visit:

1. Kempermann, Gerd and Fred H. Gage. “New Nerve Cells for the Adult Brain” in The Hidden Mind (a special edition of Scientific American).

2. The website of the Academy of Neuroscience for Architecture at which references the work of Fred Gage.

3. Hathaway, Warren E., John A. Hargreaves, Gordon W. Thompson and Dennis Novitsky. “Study into the Effects of Light on Children of Elementary School Age: A Case of Daylight Robbery” at articles_effects_of_lighting_on_school_children.cfm

4. “Daylighting in Schools: An Investigation into the Relationship between Daylighting and Human Performance” at greenschoolsfocus/DaylightingShort.pdf