Evidence-Based Design Utilized in Hospital Architecture and Changing the Design Process: a Hospital Case Study
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EVIDENCE-BASED DESIGN UTILIZED IN HOSPITAL ARCHITECTURE AND CHANGING THE DESIGN PROCESS: A HOSPITAL CASE STUDY _______________________________________ A Dissertation presented to the Faculty of the Graduate School at the University of Missouri-Columbia _______________________________________________________ In Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy _____________________________________________________ by SUINING DING Dr. Benyamin Schwarz, Dissertation Supervisor DECEMBER 2016 © Copyright by Suining Ding 2016 All Rights Reserved The undersigned, appointed by the dean of the Graduate School, have examined the dissertation entitled EVIDENCE-BASED DESIGN UTILIZED IN HOSPITAL ARCHITECTURE AND CHANGING THE DESIGN PROCESS: A HOSPITAL CASE STUDY presented by Suining Ding, a candidate for the degree of doctor of philosophy, and hereby certify that, in their opinion, it is worthy of acceptance. Professor Benyamin Schwarz, PhD Professor Ruth Tofle, PhD Professor Deanna Sharpe, PhD Professor Jane Bostick, PhD ACKNOWLEGEMENTS I consider my doctoral studies as a shared experience of intellectual and professional growth. Through this process, I was fortunate to have the opportunity to study with great mentors who have provided encouragement, guidance, and support. I am honored and privileged to have worked with Dr. Benyamin Schwarz, who recognized my passion for healthcare design research and challenged me to think critically; he is a genuinely conscientious mentor and professor who maintain the high standard and quality of academic inquiry. I am greatly indebted to Dr. Ruth Tofle, for her effort and time as the Chair for the breadth and depth of learning in the Department of Architectural Studies and her personal encouragement for my doctoral studies as a mentor. I am very grateful to Dr. Jane Bostick, whose professional insight into the field of nursing has led me to a deeper understanding of the needs for research informed healthcare design. Finally, I want to express my heartfelt appreciation to Dr. Dianna Sharpe, who has great enthusiasm and interest in my research for reviewing my dissertation. This research could not have taken place without the open door that Grand River Hospital afforded me. Their leadership and focus on patient safety and outcomes give me a new appreciation and new perspective for what healthcare design can be. I also want to express my gratitude to Sackerber Architects, for helping and supporting my research. Their approach to healthcare design convinced me that the design should be both analytical and intuitive. I wish to thank all the participants in this study, who have made my intellectual inquiry robust and thorough by sharing their experience and opinions. Finally, I would like to acknowledge the unconditional support, patience, and much more, contributed by my family. ii TABLE OF CONTENTS ACKNOWLEDGMENT …………………………………………………………. ii LIST OF FIGURES ………………………………………………………………. ix LIST OF TABLES ………………………………………………………………... xii ABSTRACT………………………………………………………………... ……... xiv Chapters CHAPTER ONE: INTRODUCTION …………………………….……................. 1 Statement of the Problem………………………………………………….. 1 Purpose of the Study ……………………………………….……………… 3 Significance of the Study …………………………………………………. 4 Theories and Theoretical Perspective …………………………………….. 5 Research Method …………………………………………………………. 9 Limitations of the Study …………………………………………………... 10 Definitions ………………………………………………………….……... 11 The Organization of the Remained of the Study ………………………….. 15 CHAPTER TWO: CRITICAL REVIEW of THE EVOLUTION OF HOSPITAL ARCHITECTURE and THE NEW WAVE – EVIDENCE-BASED DESIGN …………………………………… 17 The Ancient …………………………………………….............................. 18 The Medieval ……………………………………………………………… 20 The Renaissance …………………………………………………………... 21 The Nightingale …………………………………………………………… 24 iii The Minimalist Megahospital ………………..…………….……………… 26 The Virtual Healthscape …………………………………………............... 30 The New Wave – Evidence-based Design (EBD) …………………………33 CHAPTER THREE: LITERATURE REVIEW ………………………………….. 35 Review of Related Research in Evidence-based Design …………………. 35 Analytical and Critical Review of Theories Relevant to this Research ………........................................................................................... 38 Positive Theory and Normative Theory …………………………… 39 Procedural Theory, Design Process, and Substantive Theory………………………………………................ 42 Summary of Important Theories for This Research …...………….. 46 Lean-led Design and Lean Six Sigma …………………………….............. 47 Environment-Behavior Studies in Healthcare Environment and EB Attributes ……………………………………………………................ 52 Environmental Stress………………………………………………..58 Wayfinding …………………………………………………………62 Control …………………………………………………………….. 65 Privacy …………………………………………………………….. 68 Restoration ………………………………………………………… 71 Conceptual Framework for the Study ……………………………………... 73 CHAPTER FOUR: RESEARCH METHODS ……………………………. ………77 Philosophical Assumptions …………………………………………………77 Social Constructivism and Interpretivism …………………………………. 78 iv Grounded Theory ………………………………………………………….. 80 Research Setting ……………………………………………………………82 Research Design ……………………………………………………………85 Participants ………………………………………………………… 85 Ethical Considerations …………………………………………….. 86 Permission to Conduct the Case Study ……………………………. 87 Document Reviews ………………………………………………... 88 Direct Observations ……………………………………………….. 89 Interviews …………………………………………………………. 89 Data Analysis Strategies …………………………………………............... 92 Initial Open Coding ……………………………………………….. 95 Memo-Writing ………………………….…………………………. 97 Strategies for Validating Findings ………………………………………… 99 CHAPTER FIVE: FINDINGS ..………….………………………..………. ………101 Findings from Interviews ……………………………………….…………. 101 Axial Coding ………………………………………………………. 102 Selective Coding ……………………………………………………105 Diagram of Selective Coding for Interviews Regarding Research Question #1……………………………………….106 Storyline Memos for Interviews Regarding Research Question #1………………………………………………….108 Evidence-based Design ……………………............. 109 Design Research ……………………………………111 v Collaborations ………………………………………114 Design Innovation …………………………. ………118 Best Possible Outcomes ……………………………122 Post-Occupancy Evaluation ………….……………. 126 Diagram of Selective Coding for Interviews Regarding Research Question #2 ………………………………………129 Storyline Memos for Interviews Regarding Research Question #2 …………………………………………………132 Visioning Sessions and Design Guiding Principles……………………………………………132 Programming Process ………………………………136 Schematic Design Process ………………………….138 Research Evidence Interpretation and Implementation ……………………………………..140 Decision-Making Process …………………………..143 Contractors’ Roles in Design Process ………………145 Post-Occupancy Evaluation Feedback Session and Publication …………………………….148 Findings from Observations: Research Evidence Implemented in the Design of Grand River Hospital ……………………………………………150 Healing Environment and Positive Distractions…………………….155 Privacy …………………………………………………………….. 157 Supervision and Control ……………………………………………159 Infection Control ……………………………………………………162 Safety for Caregivers ……………………………………………….164 Safety for Patients …………………………………………………..165 vi Patient-centered Care and Restoration …………………………….. 170 Connecting with Natural Daylight and Window Views…………… 174 Walking Distance – Efficiency ……………………………………. 175 Wayfinding …………………………………………………………177 Summary of Research Evidence Implemented in the Design of Grand River Hospital ……………………………………180 Findings from Document Reviews (Data Triangulated by Interviews)……. 181 Research in Practice at Sackerber Architects ……………………… 186 Functional Performance Evaluation (FPE) at Sackerber Architects ………………………………………………………….. 190 Parametric Modeling Tool ………………………………………….199 Institute of Design Research and Evaluation (IDRE) ………………202 Implications …………………………..…………………………………….207 Redefined Model of Design Process by Integrating Evidence-based Design ……………………………………………. 208 Description and Explanation of Redefined Design Process ………..212 Design Research ……………………………………………213 Research, Evidence Generation in Practice, and New Skill Set ……………………………………………………. 214 Prediction and Evaluation – Building Mock-ups ………….. 215 User Participations ………………………………………….218 Technology …………………………………………………219 Cyclical Process not a Linear Process ………..…………….220 Conclusions………………………………………………………………… 222 vii CHPATER SIX: DISCUSSIONS ……………………………..………………….. 229 Research-Informed Design and Research-Confirmed Design and Post-Occupancy Evaluation…………………………………………………229 Environment-Behavior Studies and Theory Development…………............ 236 Sustaining the Legacy of Florence Nightingale’s Environmental Theory and Further Advance E-B Studies in Healthcare Environment......... 243 Interdisciplinary Team Approach …………………………………………..245 Research Meets Design in Practice …………………………………........... 246 Recommendations of Evidence Generation for Evidence-based Design……………………………………………………………………….248 APPENDIXES …………………………………………………………………….. 259 Appendix I: Interview Contacts and Schedule ……………………............. 259 Appendix II: Interview Protocols …………………………………………. 260 Appendix III: Observation Protocol ……..…………………………………266 Appendix IV: Sample of Observation Sheet ……………..……………….. 267 Appendix V: Informed Consent Form …………………………………….. 271 BIBLIOGRAPHY ………………………………………………………………… 274 VITA ……………………………………………………………………………….292 viii LIST OF FIGURES Figure Page Figure 3.1: Diagram of Behavioral Science and Environmental Design Theory Adopted from Lang (1987, p.24) ……………………….………40 Figure