Beyond a Reasonable DoubtCan (or Should) BIM be Evidence-Based?

Dr. Debajyoti Pati HKS Architects 14 October 2010

Presenter

Debajyoti Pati

PhD, FIIA, LEED©AP

Vice President, Director of

Research, HKS Architects

Executive Director,

Center for Advanced Design

Research & Evaluation

(CADRE)

Learning Objectives

1. Understand factors that contributed to the emergence

of the EBD model

2. Understand the fundamental essence of the EBD

practice model in healthcare

3. Illustrate how physical design is being linked to

organizational performance and bottom line

4. Explore the implications of mapping the EBD model to

BIM

Agenda

What is EBD and how it emerged?

What changes is it effecting?

Healthcare examples

Implications for BIM

Discussions

What is Evidence-Based Design

Evidence-based design

is 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.(Center for Health Design)

Is a natural parallel and

analog to evidence-

based medicine.

Applicable to all

buildings sectors.

Started in the

healthcare sector.

Emergence of EBD

1999

• Institute of Medicine

(IOM)published a report

underscoring the need for

a safer healthcare system

o 44,000 to 98,000

preventable deaths

o Deaths from preventable

medical errors exceed

deaths from motor

vehicle accident, breast

cancer and AIDS.

Emergence of EBD

2001, 2003

• Agency for Healthcare

Research and Quality

(AHRQ) highlighted the

role of the physical

environment (in addition

to the people, processes

and procedures) in

improving care quality

and safety.

EBD :: EBM

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. (Sackett D, 1996)

EBM is the integration

of clinical expertise,

patient values, and the

best evidence into the

decision making

process for patient care.

CHANGING THE DESIGNER – CLIENT

DYNAMICS

Designer’s Role

Respond to

programmatic needs

Designer’s Role

Understand:

• core organizational

needs

• business processes

SUR

GER

Y D

ECIS

ION

PR

E-P

RO

CED

UR

EP

RO

CED

UR

EP

OST

-PR

OC

EDU

RE

Designer’s Role

Identify strategic

organizational

objectives/ goals to be

targeted through

physical design

Designer’s Role

Identify and articulate

relationships between

physical design

decisions and

organizational

outcomes based on

best available

evidence

Designer’s Role

Conduct research to

inform decision-making

if evidence is not

available

Designer’s Role

Implement evidence-

based decision

Assess outcomes

Predictable

outcomes based

on available data

New knowledge

through research

Identify

Intentions/ Issues

Develop

Hypotheses

Informed

DESIGN

Collect

DATA

Evaluate

Data

Modify

Hypotheses

Disseminate

Findings

Survey

Literature

Return on Investment (Hard and Soft)

FROM ACTIVE RESPONSE TO

PROGRAMMATIC NEEDS TO

‘PREDICTABLE’ INFLUENCE ON

OUTCOMES OF ORGANIZATIONAL

INTEREST

HEALTHCARE EXAMPLES

Organizational Outcomes of Interest

Reduce patient falls

• Cost =10K un-litigated

Reduce patient transfer

• Cost per transfer = $ 300

Reduce hospital

acquired infection

• Cost per infection = 10-

30K

Nurse retention

• Cost per recruitment =

60K

Patient satisfaction

Market segment,

referrals

…

Patient Falls: Clarian Methodist Study

Objective: Test impact on new

acuity adaptable unit design on

patient outcomes

Decentralization

Room-side documentation alcove

Location: CCCC, Methodist

Clarian, Indianapolis

Procedure: Before-after study, 12

outcome measures, 2 years

baseline and 3-years post-move

data

Key finding: Patient falls declined

by 75%

Hendrich, A., Fay, J., & Sorrels, A.K. (2004). Effects of Acuity-Adaptable Rooms on Flow of

Patients and Delivery of Care. American Journal of Critical Care, 13(1), 35-45.

Patient Transfer: Clarian Methodist Study

Objective: Test impact on new

acuity adaptable unit design on

patient outcomes

Patient rooms designed to

accommodate varying acuity levels

Location: CCCC, Methodist

Clarian, Indianapolis

Procedure: Before-after study, 12

outcome measures, 2 years

baseline and 3-years post-move

data

Key finding: Patient transport

decreased by 90%

Hendrich, A., Fay, J., & Sorrels, A.K. (2004). Effects of Acuity-Adaptable Rooms on Flow of

Patients and Delivery of Care. American Journal of Critical Care, 13(1), 35-45.

Patient Visibility: Stanford-Harvard Study

Objective: Contrast safety concerns of

frontline staff with national patient safety

initiatives

Funding: AHRQ + Fishman-Davidson

Center for Service and Operations

Management

Location: 20 representative sample of

hospitals across the U.S.

Data Source: 1,732 staff-identified

operational failures (2004 – 2006)

Key finding: Top factors affecting

safety: Equipment and Facility

Tucker, A., Singer, S., Hayes, J., & Falwell, A. (2008). Front-line Staff Perspectives on

Opportunities for Improving the Safety and Efficiency of Hospital Work Systems. Health

Services Research, 43(5), 1807-1829.

Stanford-Harvard Study: Failure Sources

Equipment/ Supply

(18%)

Facility (18%)• Layout

• Maintenance +

Housekeeping

• Non-functioning

infrastructure

Communication/

Documentation (16%)

Staffing/staff

development (16%)

Medication (12%)

Process/policy (6%)

Response time (4%)

Security (4%)

Infection control (3%)

Task management (2%)

Tucker, A., Singer, S., Hayes, J., & Falwell, A. (2008). Front-line Staff Perspectives on

Opportunities for Improving the Safety and Efficiency of Hospital Work Systems. Health

Services Research, 43(5), 1807-1829.

Patient Visibility: Columbia University Study

Objective: Assess whether

patient outcomes are affected by

ICU design

Location: Columbia University

Medical Center, Medical ICU;

random room assignment

Data Source: 664 patients;

hospital mortality, ICU mortality,

ICU LOS, ventilator-free days

Key finding: Severely ill patients

had significantly higher mortality

in low-visibility rooms; 18%

higher

Leaf, D., Homel, P., & Factor, P. (2010). Relationship between ICU Design and Mortality. Chest,

Pre-published online January 15, 2010.

Infection: Canadian HAI Study

Objective: Evaluate association

between roommate exposure and

risk of HAIs

Location: A tertiary care teaching

hospital in southeastern Ontario

Procedure: Retrospective data on

adult patients between 2001 –

2005; MRSA/VRE; C difficile; total

roommates, unique roommates

Key findings: each additional

roommate

• 11% increase in C difficile risk

• 10% increase in MRSA risk

• 11% increase in VRE risk

Hamel M, Zoutman D, O'Callaghan C. (2010). Exposure to hospital roommates as a risk factor for

health care-associated infection. American Journal of Infection Control, 38(3), 173-181.

The PEBBLE Project Data Repository

PEBBLE

• Launched by the Center

for Health Design in

2000

• ~ 60 member hospitals

• Before-after and post-

occupancy data in a

central database

IMPLICATIONS FOR BIM

BIM Objectives

Enhance facility

procurement

performance

Predict built facility

performance

• Energy

• Maintenance

• Lighting

• …

BIM Status

Sophisticated

performance models

Assertions untested

• Little empirical evidence

from built facilities to

support contentions

Similar to LEED status

Standardization of

performance

measurement protocol

emerging…

• ASHRAE, USGBC,

CIBSE

Key Question

SHOULD BIM BE EVIDENCE-BASED?

Next Steps

Evidence

Base

Client

Needs

Evidence Base

Post-occupancy

performance

Pebble type

commitment

Central data base

Organizational Needs

Framing BIM within

organizational needs

• Controlling airborne

infection may be more

crucial than saving on

HVAC cost…

Situating BIM within the

larger context of

organizational

performance

• It is not necessarily about

more economic first and

life cycle cost

• It is about optimizing

facility performance to

target organizational

goals

A DIFFERENT NATURE OF

RELATIONSHIP WITH CLIENT

ORGANIZATIONS

MUST START WITH EVIDENCE

Where is the evidence?

THANK YOU