What Constitutes Best Practice in Healthcare Design?

By Hamilton, D. Kirk | HERD : Health Environments Research & Design Journal, Winter 2011 | Go to article overview
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What Constitutes Best Practice in Healthcare Design?


Hamilton, D. Kirk, HERD : Health Environments Research & Design Journal


Design practitioners who specialize in healthcare facilities are familiar with the term best practice as a result of its usage among their clients. In medicine and nursing, best practice is a familiar and accepted concept (Kenny, 2008). Best practice is a common term in education and other arenas, such as business, manufacturing, and software development. Although there is no single definition for best practice, the basic elements include practices based on the careful collection of relevant evidence, an action resulting in a positive outcome, and the ability to reproduce results. Best practice has much in common with evidence-based practice and is sometimes considered a synonym. Might there be a similar or analogous application for evidence-based architecture and engineering in healthcare facilities?

Medical Best Practice

An example from medicine is the development of clinical pathways as standards of practice in the form of protocols for treatment. Another example is the Cochrane Collaboration (www.cochrane.org), a nonprofit organization that exists for the purpose of providing critical reviews of evidence in medicine and healthcare (Bero & Rennie, 1995). Their model is to provide independent, expert evaluations of the quality of the best available evidence for a given topic and to publish thorough and systematic reviews.

Rating the quality of evidence becomes a crucial issue. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group (www.gradeworkinggroup.org) points out the potential confusion associated with the multiple scales proposed for evaluating evidence. After examining the different evaluation scales available, GRADE chooses to classify evidence as high, moderate, low, or very low. GRADE also offers a nine-point scale of importance based on outcomes (Guyatt et al., 2008). The top three points are considered critical for decision making, the middle three points are important but not critical to decisions, and the lower three points of the scale denote outcomes of less importance to patients and unimportant for decision making.

In the case of the American College of Chest Physicians (Guyatt et al., 2006), recommendations or guidelines are classified as strong (1) or weak (2). The quality of the evidence supporting a recommendation is rated as high (A), moderate (B), or low (C). Thus a 1A recommendation is a strong recommendation based on evidence of high quality, and a 2C recommendation is a weak recommendation based on evidence of low quality.

Nursing Best Practice

As nursing turns toward an evidence-based practice model, its attention to best practice increases. "Best practice refers to the clinical practices, treatments, and interventions that result in the best possible outcome for the patient and the health care facility providing those services" (Munden & Lockhart, 2007, p.1). The American Association of Critical-Care Nurses (AACN) has revised its system of evidence levels (Armola et al., 2009). Level A now refers to meta-analysis of multiple controlled studies or metasynthesis of qualitative studies; Level B is for controlled studies that are well designed, randomized or not; Level C is a catchall for qualitative studies, descriptive or correlational studies, systematic reviews, and controlled trials with inconsistent results; Level D is for peerreviewed standards published by professional organizations; and Level E is for expert opinion based on theory or multiple case reports. Level M is reserved for the recommendations of manufacturers. In a recent editorial, Jaynelle Stichler (2010) proposed a numbered set of levels similar in content to the AACN levels that could be used by the readers of HERD to evaluate the evidence that appears in this journal. (See Table 1.)

Although the trend toward evidence-based practice and the documentation of best practice is strong, some clinicians object. Some feel that their integrity, training, education, and experience are being ignored as clinical pathways overwhelm individual decisions.

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