Stichler, Jaynelle F. DNSc, RN, FACHE, FAAN
Nursing as a profession recognizes the value of accreditation and certification in clinical and managerial specialties. Many professional organizations offer certifications including AONE and the American Nurses Credentialing Center. In addition, nurse executives may elect to be certified by the American College of Health Care Executives. Nursing schools are also accredited by several professional bodies who review the schools' scholarly work, the faculty's credentials, and the success of the graduates. So what is the purpose of all of these credentials and accreditations? For the most part, they indicate a specific standard of knowledge and experience beyond the minimum expected of a licensed or registered professional. Most certifying and accrediting bodies provide a content outline of required areas of knowledge, an expectation of a number of years of experience, and a test that measures the applicants' recall, recognition, and application of knowledge in the specific area of expertise. It may surprise some reading this article that there is also a certification for healthcare providers and design professionals indicating a level of knowledge and expertise in evidence-based design. The purpose of this article is to describe the Evidence-Based Design Accreditation and Certification (EDAC), the vision and mission of the Center for Health Design who administers the EDAC, and the knowledge/experience expected of those aspiring this certification.
Vision and Mission of EDAC
Prior to EDAC, there was no mechanism for recognizing design professionals who truly had the knowledge of healthcare clinical operations or patient and staff needs to enable them to adequately design healthcare facilities. Any firm could acclaim that their designers were capable of designing multimillion and sometimes billion-dollar projects without adequate education or experience to support such claims. At times, friends of members of the Board of Directors or the executive team were chosen for projects because they aspired to enter the healthcare design field, and subsequently, the projects experienced significant difficulties with cost overruns, schedule and construction delays, and multiple owner- and architect-initiated change orders. Most importantly, patient safety and healthcare provider work life were compromised.
The Center for Health Design (www.healthdesign.org) initiated an interdisciplinary process with architects, interior designers, nurses, and physicians to explore a mechanism to recognize a core body of knowledge and experience for both designers and providers to lead healthcare design projects. The vision was that all healthcare environments would be designed using an evidence-based approach "using the most current research and thinking to support the best outcomes for the people who spend time in hospitals."1(p3) The group developed some core beliefs to guide its mission, which stated: "We believe, at a minimum that
* patients should be able to devote their energies to getting well without having to fight their environments.
* doctors, nurses, and staff should be able to go to work every day without worrying about getting sick or injured because of the design of the environment, and
* sustainable building using evidence-based designs can improve the quality of care, save lives, provide more cost-effective healthcare, and create a healthy planet."1(p.vii)
The mission was to develop a group of dedicated and disciplined professionals who would acquire specific knowledge related to healthcare and evidence-based design, achieve a specific level of experience, and use evidence to guide healthcare design decisions and to recognize these individuals with a certification in evidence-based design. The EDAC is one of the few interdisciplinary certifications, and it is offered to both design and healthcare professionals. The entire process to develop EDAC was funded by The Robert Wood Johnson Foundation, Nurture by Steelcase, and the Center for Health Design, who all embraced the IOM's quality aims that patient care be patient centered, safe, timely efficient, effective, and equitable.2
Content Knowledge Areas for EDAC
The intent of the EDAC initiative is to reduce the stress experienced by patients, their families, and the teams of professionals caring for them by creating environments that are supportive to patient healing (patient satisfaction, reduced lengths of stay, reduced readmission rate, lack of errors, and reduced rates of nosocomial infections, patient falls, and hospital-acquired pneumonias), staff efficiency (productivity, quality indicators, and staff satisfaction), and organizational effectiveness (increased market share and financial outcomes). The EDAC addresses content in the following areas: (1) an introduction to evidence-based design, (2) key trends and challenges in healthcare today, (3) an introduction to research, (4) methods for finding and using relevant evidence related to healthcare design, (5) steps to developing new evidence, (6) processes in creating interdisciplinary teams for design, and (7) phases of the design process through construction and postoccupancy evaluation. The content outlines, summaries, and postexaminations were all developed by a team of volunteers recognized for their expertise in healthcare quality and delivery and healthcare design fields. The content was compiled into 3 volumes published by the Center for Health Design.1,3,4
Introduction to Evidence-Based Design
This section of the EDAC study guide provides a definition of evidence-based design that was adapted from Sackett and colleagues'5 original definition by Stichler and Hamilton6: "a process for the conscientious, explicit, and judicious use of current best evidence from research and practice in making critical decisions, together with an informed client, about the design of each individual and unique project."6(p3) The background behind the evidence-based design process as a means of designing hospitals that would potentially reduce errors and address the current healthcare trends is provided.
Key Healthcare Trends and Challenges
The intent of this section is to provide healthcare providers and executives and design professionals with an overview of the public's focus on quality and safety in healthcare including the IOM's7 and HealthGrades' report on patient safety.8 The study guide describes how reimbursement challenges have added to the necessity of designing new healthcare facilities with the intent to create a stage where providers can eliminate error and hospital-acquired complications. Trends in the effect of an aging population, health information technology, and genomics and technology on healthcare design are outlined. Also included are sections addressing emergency room surge and capacity from appropriate and inappropriate use and the ability of American hospitals to respond to natural disasters and potential terrorist attacks. The importance of designing sustainable healthcare environments to address internal and external environmental safety and the need to help hospitals become better world citizens through sustainable design are discussed. Finally, the chapter ends with an overview of the roots and evolution of the evidence-based design initiative with examples of current projects designed and built with an evidence-based approach.
One of the major challenges in evidence-based design is to integrate the knowledge of healthcare with that of design. Whereas most healthcare leaders understand the structure and ownership status of hospitals, many healthcare designers do not, so the preparation for EDAC certification includes an overview of the different types of models for healthcare organizations and their classifications by (1) length of stay (inpatient, outpatient, long-term care) and service (acute care or specialty care); (2) access (community, government); (3) location (rural or urban); (4) size (number of beds); (5) ownership (for profit or non-profit); and (6) academic or community. The effects of these on the design and decision-making process coupled with the organizations' culture, mission, and strategic vision are discussed. Key stakeholders in the design process are outlined, helping the reader to assimilate the importance of including these key stakeholders to broaden input into the design of clinically sensitive areas and to enhance ownership of the overall building design.
An Introduction to Research
Not all designers and healthcare providers and executives are well grounded in research theory and methodology, but both industries are eager to increase their knowledge and skill in applied and basic research. The EDAC initiative includes content to enhance knowledge about quantitative and qualitative research methods, mixed-methods approaches, measurement tools and methods, and use of existing data to measure the effect of specific design features on patient, provider, and organizational outcomes. Of course, the first task is to help both healthcare providers and designers to ask the right questions and to find and use relevant data to guide design decisions as contrasted to using only empirical data sources, the latest trendy designs, or personal preferences. Significant information is provided about the types of resources that can be accessed to enhance one's knowledge about the effect of the built environment on outcomes and the level of evidence that is provided in the sources. Resources such as journals, academic papers, conference proceedings and presentations, archival material, and in-house case studies are all outlined as possible sources of evidence. Steps are provided to access the information from online journals, databases, abstracting and indexing services, in-house databases, search engines, Web sites, federated search technologies, and open-archives initiatives.
As nonacademic researchers, most healthcare providers and designers are novices in evaluating and appraising the validity and reliability of existing evidence in published research findings and in determining the relevancy of the evidence to their own projects. The EDAC initiative provides an explanation of these research terms and methodologies that can be followed to compile a source of evidence in a systematic, retrievable manner and to appraise its validity, reliability, and application.
The EDAC study guides distinguish between using evidence to guide design decisions with generating new evidence through research to test new theories or examining the effectiveness of design features. Research has a common language despite the discipline; therefore, EDAC emphasizes the need to generate a clear, concise research question or hypothesis related to the association of design features with expected outcomes, methods to measure the outcomes appropriate to the study design, potential data collection procedures to ensure ethical standards, and data analysis techniques. Finally, possible ways to disseminate the findings at conferences or peer-reviewed journals such as Health Environments Research & Design Journal, Environment and Behavior, The Journal of Nursing Administration, or other clinical specialty journals are discussed. The intent is to encourage the sharing of evidence that can be used in future design projects.
Integrating Evidence Into Design
There is an obvious parallel between the evidence-based design initiative with that of evidence-based practice in nursing and medicine. One of the most important beliefs and attitudes that must be managed is the acceptance by all parties that an interdisciplinary approach to design or to care will result in improved outcomes. In nursing, a collaborative approach to care has been reported to improve patient outcomes and nursing satisfaction. Similarly, an interdisciplinary approach to the predesign and design process has been shown to improve the final building design as measured by the hospital's satisfaction with the design and compliance with the projected project scope, budget, and schedule. Steps of how to identify and engage key stakeholders are discussed in the EDAC study guides.
The industry is still learning to measure both organizational and patient outcomes, but it is expected that future research findings will address the effect of specific design features on well-measured outcomes.
The EDAC preparation includes a review of the integration of the hospital's vision, mission, and strategic plan with the project's aim and targets. The development of a business model addressing critical successful factors and how to measure them in terms of return on investment, payback periods, and integration of design and construction to reduce payback periods is discussed.
Just as designers are unfamiliar with how hospitals are organized and key healthcare trends that might affect hospital design, providers are equally unprepared as to how the design process emerges over time and when to best provide necessary input. The EDAC prepares the healthcare provider with a thorough explanation of each step of the design process from predesign, conceptual design, schematic design, design development, construction documents, and postoccupancy evaluation. Innovative solutions to test design concepts before they are built in concrete and steel are presented, giving the reader a framework for recommending mock-up rooms, computer simulations, and evaluation models such as the Baldridge Award, the Joint Commission, or other methods to evaluate the design to ensure that they address clinical and safety outcomes, financial and economic goals, and satisfaction, commitment, and support measures.9
A step often missed in published findings of newly built healthcare projects is a reporting of the business case outcomes. The EDAC includes content related to describing the business case including a description of operational change requirements, implementation strategies, and financial and business outcome measures. The EDAC preparation also includes discussion of the preconstruction bid, negotiation, and award processes, which are often not familiar to healthcare providers and leaders but are critical to the project's budget and schedule for opening. Nurse leaders will be particularly interested in EDAC's emphasis on preparing for postoccupancy including process mapping, staff training schedules, cultural training, and commissioning of the new building with all of the owner requirements for commissioning.
Implications for Nurse Executives
The EDAC provides a concrete way to recognize design professionals and healthcare providers who are educationally prepared and experienced in evidence-based healthcare design. The preparation for the EDAC examination provides a breadth of information that will be most useful to nurse executives anticipating or currently engaged in a design project and will facilitate action plans to engage an interdisciplinary, evidence-based approach to the design. Nurse executives who are on selection committees charged with choosing the design firm who will lead the design efforts and who seek firms with a number of EDAC-certified designers ensure that the design team will have the knowledge and belief that using an evidence-based approach is important and the skills to apply the process in the proposed project's delivery. For nurse leaders who have interest in career options in healthcare design in the hospital as project leaders or in design firms, the EDAC preparation is a first step to enhance one's knowledge of the process. For more experienced nurse leaders and consultants, the EDAC certification validates your experience and comprehensive knowledge in evidence-based design. The EDAC has value to healthcare leaders, providers, and designers.
© 2010 Lippincott Williams & Wilkins, Inc.