Indoor Environmental Quality and Health Improvement, Evidence-Based Design for 307 Indoor Environmental Quality IEQ (indoor environmental quality) Beyond IAQ to encompass all aspects of the indoor setting includ- and Health Improvement, ing air quality, thermal, visual, and acoustic quality. Evidence-Based Design for Focuses on the strategies and systems that resultCHARLENE W. BAYER in a healthy indoor environment for buildingGeorgia Tech Research Institute, Georgia Institute occupants.of Technology, Atlanta, GA, USA WHO (World Health Organization) A United Nations agency that coordinates international health activities and aids governments in improvingArticle Outline health services.Glossary Definition of Evidence-Based DesignDeﬁnition of Evidence-Based DesignIntroduction Evidence-based design (EBD), as deﬁned by the CenterApplication to Healthcare Facilities for Health Design , is “the process of basing deci-Application to Other Types of Facilities sions about the built environment on credible researchFuture Directions to achieve the best possible outcomes.” EBD is anSummary/Conclusions approach to facilities design that treats the buildingBibliography and its occupants as a system and gives importance to design features that impact health, well-being, mood and stress, safety, operational efﬁciency, and econom-Glossary ics. To date, EBD has been applied primarily to healthcare facility design, where it has been shown toAIA (The American Institute of Architects) The AIA frequently reduce costs, improve staff productivity, and has been the leading professional membership asso- decrease the length of patient hospital stays. The evi- ciation for licensed architects, emerging profes- dence-based designer, in collaboration with the sionals, and allied partners since 1857. informed client, develops appropriate solutions to theCfm (cubic feet per minute) A non-SI (non- individual design project based on the needs and International System) unit of measurement of the expectations of the client, research on similar projects, ﬂow of a gas or liquid that indicates how much and experience . EBD provides data on successful volume in cubic feet passes by a stationary point strategies for the design process for healthy, high qual- in one minute. The ASHRAE standards and guide- ity buildings. lines give ventilation rates for the IEQ in a speciﬁed number of cfm/person. 1 cfm = 0.472 L/s.EBD (evidence-based design) The process of basing Introduction decisions about the built environment on credible Concepts research to achieve the best possible outcomes.Health A state of complete physical, mental, and social Healthy, high-performance buildings should have pos- well-being and not merely the absence of disease or itive outcomes in terms of energy, sustainability, health, inﬁrmity. and productivity. A healthy building should meet theHVAC (heating, ventilation, and air-conditioning World Health Organization (WHO)  deﬁnition of system) The systems used to provide heating, health, “a state of complete physical, mental and social cooling, and ventilation in buildings. well-being and not merely the absence of disease orIAQ (indoor air quality) The air quality within build- inﬁrmity”. The use of this deﬁnition of health is partic- ings, related to conditions around buildings and ularly applicable to green buildings, intent on not only structures, and its relationship to the health and reducing exposures to chemicals, but also promoting comfort of building occupants. exercise, lowering stress, increasing social interactions,V. Loftness, D. Haase (eds.), Sustainable Built Environments, DOI 10.1007/978-1-4614-5828-9,# Springer Science+Business Media New York 2013Originally published inRobert A. Meyers (ed.) Encyclopedia of Sustainability Science and Technology, # 2012, DOI 10.1007/978-1-4419-0851-3
308 Indoor Environmental Quality and Health Improvement, Evidence-Based Design for and otherwise fostering physical, social, and mental framework groups physical environmental variables health for the occupants. EBD not only meets the into two primary groups: (1) IEQ variables including WHO health deﬁnition, but also encompasses produc- noise, lighting, ambient temperature, and IAQ, and tivity, operational efﬁciency, economic performance, (2) interior design variables including use of space, and occupant/customer satisfaction. Effective EBD furniture, ﬁxtures and equipment, ﬁnishing materials, needs to be combined with sustainable design, incor- color, artwork, natural views, and environmental porating all practices that reduce the negative impact of graphics. These variables are interlinked in the design development on ecological health and indoor environ- of the indoor environment and its conditioning sys- mental quality . tems. Factors leading to stress, similar to individual Sustainable, creative design features for application responses to odors, vary among individuals, further of EBD fall into four major categories, which impact complicating the issues . The collaboration between health, economic performance, and operational efﬁ- the designer and the user in the EBD design process is ciency of the building system: critical in reducing stressors in the indoor environment. Examples of potential environmentally induced ● Innovative building enclosures that incorporate stressors that need to be assessed in the EBD process load balancing, natural ventilation, and daylighting are: ● Advanced HVAC systems that incorporate natural conditioning, increased environmental contact, and 1. Open ofﬁce plans creating feelings of lack of local control privacy  ● Innovative data/voice/power “connectivity” and 2. Open ofﬁce plans, selection of hard-surfaced ﬂoor- individual control ing and furnishing materials, ofﬁce equipment ● New interior system designs in workstations and location, HVAC system vibration, and/or or out- workgroup designs for improvements in spatial, door trafﬁc that may increase noise levels resulting thermal, acoustic, visual, and IAQ parameters  in difﬁculties in concentration, speech intelligibil- ity, headaches, and other physical and emotional Innovative enclosures and advanced HVAC systems stress responses that impact learning and produc- particularly impact IAQ, health, productivity and tivity [9–11] learning, stress reduction, and operational economics. 3. Cafeteria, cleaning, furnishings, or systems odors Innovative connectivity and new interior system permeating throughout the work areas of a building designs chieﬂy impact health both as physical well- due to improper ventilation system design or poor being and social well-being via connectivity to the materials selection [12, 13] organization as a whole, stress reduction, and health. 4. Daylight glare on work surfaces due to lack of effective window glazing or absence of blinds, and Indoor Environmental Quality unshielded electric lighting that may result in head- aches or eyestrain and poor productivity [14–16] Healthy buildings encompass all aspects of indoor envi- ronmental quality (IEQ) including optimum thermal The Academy of Neuroscience for Architecture comfort, lighting with effective daylighting and access to (www.anfarch.org) is using evidence-based design as views, IAQ, acoustical performance, ventilation effec- a means to assess the linkage between neuroscience tiveness integrated with natural ventilation when appli- research and human responses to the built environ- cable, and human comfort and health. Healthy buildings ment; thus seeking to relate behavioral changes to are designed for ease of operation and maintenance, brain function changes based on the built environment. because buildings with inadequate IEQ adversely The Academy, in its studies, deﬁnes the dimensions of impact occupants’ overall health and productivity. functional comfort as: (1) air quality, (2) thermal com- Rashid and Zimring  suggest that poor indoor fort, (3) spatial comfort, (4) collaborative or environments may initiate a process leading to stress teamspace, (5) visual comfort, (6) workstation com- whenever the individual or workplace IEQ does not fort, (7) lighting quality, (8) noise control, and (9) meet an occupant’s needs, as is shown in Fig. 1. Their security. These nine parameters are used to direct the
Indoor Environmental Quality and Health Improvement, Evidence-Based Design for 309 A conceptual framework describing how the physical environment may set in motion a process leading to stress The physical environment Personal motives and Immediate outcomes attitudes Individual within a building Negative environmental outcomes demographic factors coping Examples – increased noise, Indoor environment Age, sex, health uncomfortable temperature, skills status, education, poor lighting, poor air quality Noise social and Sick building syndrome Lighting condition cultural background Physiological Ambient temperature Examples – Headache, Air quality sweating, muscle tension, The overall quality of the higher blood pressure and Individual needs and Indoor environment heart rate their perceived importance in a context Psychological + or – + or – + or – Examples – worrisome Stress Architectural and/or interior Physiological thoughts, feelings of design Psychological helplessness, fear, and/or Global sadness Cognitive Building Cognitive Configuration, layout Psychosocial Examples – reduced Task of Rooms, functional Social performance, difficulties in relations wayfinding Local Psychosocial Room configuration, Examples – dissatisfaction, Furniture layout, discomfort, inconvenience, Interior details, reduced sense of control, Finish materials, privacy, territoriality, and/or Color, artwork, Organizational Factors Time safety, increased sense of Nature, View, crowding Environmental Social Graphics Examples – lack of group interaction and social supportIndoor Environmental Quality and Health Improvement, Evidence-Based Design for. Figure 1Rashid and Zimring  conceptual framework describing how the physical environment may initiate a process leading tostressevidence-based design practices to reduce human low-emitting and eco-friendly include ofﬁce furniture,stress, poor behaviors and attitudes, and overall ﬂooring, paints and coatings, adhesives and sealants,human health, as deﬁned by WHO. wall coverings, wood products, textiles, insulation, and cleaning products. The potential adverse healthIndoor Air Quality The primary design strategies impacts of pollutants that may emit from these prod-that are used to improve IAQ in green buildings are ucts has been determined though many emissionsthe use of low-emitting furnishings and building mate- investigations .rials, designed to meet an iteratively tightening set of Another strategy available for reducing exposuresstandards [17–20]. This strategy addresses one of the to airborne contaminants is source control of indoormost important IAQ determinants that is clearly in the equipment and activities. Ofﬁce machines, stoves, andrealm of the designer – source control. However, the other appliances that are known to be active pollutantconstruction process, including installation sequence generators beneﬁt from the use of local source controland protection of materials prior to installation, is via the installation of dedicated exhaust fans. The use ofalso an important factor to be addressed by the EBD local source control systems needs to be part of theteam. Installation of carpet prior to painting of walls design process and the location of the areas needingcan result in long-term low level emissions of paint dedicated ventilation and exhausts need to be deﬁnedfumes due to adsorption by the carpet and slow early in the design process. The use of well-maintainedreemission into the indoor environment. Key furnish- air cleaners is another strategy that may be appropriate toing and material sources that must be speciﬁed as selected areas and types of facilities, such as in hospitals.
310 Indoor Environmental Quality and Health Improvement, Evidence-Based Design for Ventilation systems are the primary method to providing the ability for occupants to individually con- dilute and transport airborne contaminants out of trol the ambient temperature. the building. Natural and mixed-mode systems, if Numerous studies show health, productivity, and employed, must be designed to provide sufﬁcient pol- learning improvements with higher ventilation rates; how- lutant dilution and transport out of the building. ever, this must also be balanced with sustainable design for greater energy efﬁciency through the use of innovative Ventilation System Design/Environmental Control ventilation systems and maximizing ventilation efﬁciency. The ventilation system is the primary means of Haverinen-Shaughnessy et al.  found a linear associ- transporting contaminants into, throughout, and out ation between classroom ventilation rates within the of the indoor environment. The placement and design range of 0.9–7.1 L/s/person and students’ academic of the system is critical to the quality of the indoor achievement. In this study of ﬁfth graders, it was deter- environment. Superior ventilation has been shown to mined that for every unit (1 L/s/person) increase in the improve learning, productivity, satisfaction, and ventilation rate, the proportion of students passing health. At the same time the ventilation system can standardized tests increased by 2.9% for math and transport unwanted outdoor pollutants indoors, trans- 2.7% for reading. Studies have shown that occupants fer indoor pollutants from one space to another, or in buildings or spaces with higher ventilation rates on transport infections . average have fewer communicable respiratory illnesses, In most buildings, the ventilation system is linked and lower asthma rates, and fewer absences from work to the thermal conditioning (temperature control) or school [30–32]. The European Multidisciplinary system. Combined thermal comfort and ventilation Scientiﬁc Consensus Meeting (EUROVEN)  systems may inadvertently compromise ventilation found that ventilation is strongly associated with per- potentially adversely impacting IEQ, health, and occu- ceived air quality and health (sick building syndrome pant satisfaction. If a decision has to be made between symptoms, inﬂammation, infections, asthma, allergy, thermal comfort and ventilation response, EBD reveals short-term sick leave) and that there is an association that the lack of temperature control is a primary between ventilation and productivity in ofﬁces. The stressor in the indoor environment, impacting produc- EUROVEN group also concluded that outdoor air sup- tivity, learning, mood, and overall health . ply rates below 25 L/s/person increased the risk of sick On the other hand, lower temperatures, especially building syndrome symptoms, increases in short-term when combined with increased ventilation rates, tend sick leave, and decreased productivity among occu- to increase productivity and student performance. pants of an ofﬁce building. Additionally improper Wargocki and Wyon found that lowering the classroom maintenance, design, and functioning air-conditioning temperature approximately 5 C improved elementary systems contribute to increased prevalence of sick school students’ performance on two numerical tasks building syndrome symptoms. and two language-based tasks [24, 25]. The children The research clearly demonstrates signiﬁcant asso- also reported lower incidence of headaches. When the ciations between ventilation system design that allows classroom effective outdoor air supply rate was raised increased levels of ventilation, at least 10 L/s per person from 11 cfm/person (5 L/s) to 20 cfm/person (10 L/s), of outdoor air supply in buildings for optimized health, the students’ performance was improved on four productivity/learning, and reduced stress. In order to numerical tasks by improving the task performance meet sustainable design practices meeting the goal of speed. The children also reported feeling that the air energy efﬁciency and reduced operating costs, innova- felt fresher with the lower ambient temperatures. Sim- tive ventilation strategies and systems must be used. ilar results on the relationship of temperature and Natural ventilation and hybrid systems are important ventilation on productivity have been reported in innovative approaches, to be combined with next gen- adult work situations [26–29]. As a result, EBD reveals eration active systems. the importance in the design of the environmental control/ventilation system of separating the ventilation Lighting/Daylighting/Access to Views Studies have system from the thermal conditioning system and shown that daylighting has a positive impact on
Indoor Environmental Quality and Health Improvement, Evidence-Based Design for 311humans, improving accuracy of work performance, privacy include possibly reconsideration of the openreducing stress and fatigue, and improving patient out- ofﬁce plan, designing private areas adjacent to the opencomes . Loftness et al.  found that improved ofﬁce area for use in private situations as needed, orlighting quality design decisions are linked with increasing background noise. A lack of speech clarity0.7–23% gains in individual productivity. The lighting occurs when the acoustics or a room design deterioratequality design ranged from indirect–direct lighting sys- the acoustical communication channel, renderingtems, higher quality ﬁxtures, and daylighting simula- speech to the intended listener unintelligible, creatingtion. When daylight responsive dimming was communication problems. This is particularly an issueemployed energy savings of 27–87% were realized. in school classrooms and conference rooms. The prob- Access to the natural environment is associated lem may be caused by excessive background noise orwith individual health and productivity. Design deci- excessive reverberation. EBD solutions to improvesions for exposure to views include access to windows acoustics while maintaining sustainable design strate-and view, daylighting through windows and skylights, gies include the use of acoustically absorbing materials,natural and mixed-mode ventilation systems, and such as ceiling absorbers, acoustical ceiling tiles or wall-direct accessibility to landscaped indoor and outdoor mounted panels.spaces. Access to the natural environment has beenshown to result in 3–18% increases in individual pro- Operation and Maintenanceductivity  including access to operable windows. A critical area that EBD needs to address for long-term Evidence from school lighting research indicates that building sustainability and occupant health is design-improved school lighting can enhance both visual ing for maintainability. The life-cycle costing must(healthy vision) and non-visual (achievement out- include the maintenance and operating costs over thecomes). Lighting conditions in classrooms have impor- facilities lifetime, and EBD feedback on the long-termtant non-visual effects on students including potentially integrity and maintainability of the materials, compo-raising test scores and faster responding on tests . nents or systems. Metrics should be deﬁned during the design process for the ability to maintain the facility inAcoustics/Noise Control Acoustics is an area of con- order to meet health and client economic performancetinued dissatisfaction in many green buildings . In needs. These metrics, at a minimum, should include:a number of projects, the open plan design, large areasof glass, hard-surface materials and furnishings, and ● Labor hours per year that will be required to main-natural ventilation strategies used in many green build- tain each integral part of the facility, such as theings have led to ongoing concerns with acoustic condi- HVAC system(s), the electrical system, lighting,tions. Building acoustical problems are generally windows, skylights, ﬂoors, and furnishingsclassiﬁed in three categories: excessive noise, lack of ● Frequency, extensiveness, and difﬁculty to performspeech privacy, and lack of speech clarity. Excessive required cleaning (including avoided toxicity)noise is usually the result of high background noise ● Cost of cleaning and replacement materialsemanating from outdoor noise sources that are trans- ● Equipment and furnishings life expectanciesmitted through to the indoor environment, as well as ● Training costs in labor hours and dollars for main-noise from other rooms, building equipment, and/or tenance staff and occupants/building usersnoise from other occupants. Acoustical design strate- Magee  deﬁned the speciﬁc maintenance objec-gies need to control noise levels at the source, reduce tives of the majority of facilities as follows:sound transmission pathways, and employ sound iso-lation techniques. Speech privacy is the extent to which ● Perform necessary daily housekeeping and cleaningspeech is unintelligible to an unintended listener. The to maintainworst speech privacy situations are those where the ● Promptly respond and repair minor discrepanciesbackground noise is very low. In open ofﬁce plan envi- ● Develop and execute a system of regularly scheduledronments, the lack of speech privacy may be a signiﬁ- maintenance actions to prevent premature failure ofcant stressor. Design strategies to help improve speech the facility, its systems, and/or components
312 Indoor Environmental Quality and Health Improvement, Evidence-Based Design for ● Complete major repairs based on lowest life-cycle satisfaction. Maintenance-related problems over a costs building’s lifetime can be minimized by making appro- ● Identify and complete improvement projects to priate design decisions early in the process. reduce and minimize total operating and mainte- For example, maintainability is a critical measure nance costs without increasing indoor toxicity for the performance for all ventilation systems includ- ● Operate the facility utilities in the most economical ing innovative high-performance ventilation systems manner that achieves reliability and optimum func- and may have a signiﬁcant impact on the health of tioning, while minimizing or eliminating indoor the building occupants. In a study conducted by toxicity Bayer et al.  on the beneﬁts of active humidity ● Provide for easy and complete reporting and iden- control and continuous ventilation at a minimum tiﬁcation of necessary repair and maintenance work level of at least 15 cfm/person in schools using high- ● Perform accurate cost estimating to ensure lowest efﬁciency total energy heat recovery desiccant cooling cost and most effective solutions ventilation system, the importance of system particu- ● Maintain a proper level of materials and spare parts late ﬁlter maintenance was clearly demonstrated. As to minimize downtime can be seen in Fig. 2, the carbon dioxide (CO2) con- ● Actively track all costs of maintenance work centrations in the classroom exceeded 2,000 ppm dur- ● Schedule all planned work in advance allocating ing occupied times in the classrooms prior to and anticipating staff requirements to meet planned replacement of the particulate ﬁlter in the system. and unplanned events Once the ﬁlter was changed, reducing the impedance ● Monitor progress of all maintenance work to outside air delivery, the CO2 levels dropped to ● Maintain complete historical data concerning the approximately 800–1,000 ppm during occupied facility in general and equipment and components periods of the classroom. This result clearly demon- in particular strates the necessity of system maintenance for effective ● Continually seek workable engineering solutions to ventilation even when a high-efﬁciency ventilation sys- maintenance problems tem is employed. In this school, ﬁlter replacement was inadequate due to difﬁculty in accessing the ﬁlter for Maintenance has a considerable impact on a build- replacement, a design and maintenance ﬂaw. ing’s performance and upon occupants’ health and CO2 Fingerprint School J 12/98 - 3/99 3500 3000 After filter change CO2 Concentration 2500 Christmas 2000 Break 1500 1000 500 0 1 151 301 451 601 751 901 1051 1201 1351 1501 1651 1801 1951 2101 2251 2401 2551 2701 2851 3001 3151 3301 3451 3601 3751 3901 4051 4201 4351 4501 4651 4801 4951 Hour of Sampling Indoor Environmental Quality and Health Improvement, Evidence-Based Design for. Figure 2 CO2 levels demonstrate the importance of particulate filter maintenance for effective ventilation in an occupied classroom
Indoor Environmental Quality and Health Improvement, Evidence-Based Design for 313 Maintaining the cleanliness of the ventilation ﬁlters receiving from clients and tenants concerned issues ofhas been found to impact productivity and learning in ease of repair, access to cleaning area, and ease ofofﬁce buildings and schools. Wargocki et al. , in cleaning. Property managers also reported frequentlya study on the performance and subjective responses of receiving similar complaints. The design ﬁrms consid-call-center operators, found that replacing a used ﬁlter ered themselves to be knowledgeable in maintenancewith a clean ﬁlter reduced operator talktime by about issues and design, and stated that they consulted prop-10% at a outdoor air supply rate of approximately erty managers and maintenance consultants during the34.4 L/s, but no effect was noted when the ﬁlter was designing of selected projects, primarily in the sche-replaced and the outdoor air supply rate was only matic and preliminary design phases.34.4 L/s. Additionally the operators reported a decrease This is an area where EBD demands increased col-in sick building syndrome symptoms with clean ﬁlters laboration among all of the interested parties through-and the increased ventilation rates. out the entire design process. EBD maintenance These investigations clearly demonstrate the impor- planning and design will enhance the life-long perfor-tance of ﬁlter changeouts and ventilation system main- mance of the building.tenance for IEQ, health, and productivity. The buildingsystems need to be designed for easy performance of Human Factor Impacts/Occupant/Customerventilation system maintenance tasks. Satisfaction on Sustainable Designs Arditi and Nawakorawit  surveyed 211 of thelargest US building design ﬁrms to investigate the rela- Many sustainable design strategies reduce the use oftionship between design practices and maintenance walls and partitions – with more open space planning –considerations. The study examined the extent to to reduce material use, enhance views and daylight, andwhich maintenance issues are considered when increase ventilation airﬂow, particularly when naturaldesigners specify building materials and service equip- and hybrid ventilation strategies are used. Althoughment; the level of designers’ knowledge in mainte- this may increase satisfaction with daylight and accessnance-related issues; the degree to which design to views, it may also increase dissatisfaction with noise,personnel are exposed to training in maintenance- privacy, and the ability to concentrate . This situ-related matters; the extent to which designers consult ation was encountered in the LEED Platinum certiﬁedproperty managers and maintenance consultants; the Philip Merrill Environmental Center in Annapolis, MDrelative importance of maintenance issues to other . This facility placed the entire workforce into andesign factors; the level of difﬁculty in cleaning, open plan setting, regardless of status in the company,inspecting, repairing, and replacing various building including the president and the key executives, withoutcomponents; and the magnitude and frequency of doors and low partitions for almost all employeesmaintenance-related complaints that designers receive (Fig. 3). This allows access to views and daylightingfrom clients and tenants. Their ﬁndings indicate that for all employees and the occupants’ satisfaction ratingsmaintenance consideration follow cost and aesthetics are very high. However, the primary complaints thatissues when designers specify building materials, but remain are lack of privacy, noise, distractions, andmaintenance considerations constitute the number one interference with work concentration. At the sameissue when specifying service equipment. For most time, the occupants rated the views, daylighting, andﬁrms, the mechanical system was considered to be the interactive behaviors and communication highly.most important consideration with regard to difﬁculty Evidence-based design is an effective strategy forof cleaning, inspection, repair, and replacement with determining the potential effectiveness of open spaceboth the designers and the property managers. How- planning in different types of buildings and task situa-ever ease of repair and replacement, access to cleaning tions [39, 40]. For example, an elementary school inarea, and ease of cleaning were ranked by designers to Atlanta, GA, organized in pods, uses four-foot highbe among the least important design factors for build- partitions among lower grade classrooms in each poding systems and the facility. This in spite of the fact that rather than ﬂoor-to-ceiling walls to increase interac-the primary complaint that designers reported tion between grade classes. The partition heights
314 Indoor Environmental Quality and Health Improvement, Evidence-Based Design for Indoor Environmental Quality and Health Improvement, Indoor Environmental Quality and Health Improvement, Evidence-Based Design for. Figure 3 Evidence-Based Design for. Figure 4 Open floor plan at Philip Merrill Environmental Center. Open classroom style at Atlanta, GA, elementary school Picture available at http://www.cbf.org/Page.aspx? pid=445 efﬁciency, and customer satisfaction. EBD helps to provide solutions to the healthcare challenges of cost increase as the grade level increases until in ﬁfth grade control, ﬁnancial stability, avoidance of harm, quality (Fig. 4), the traditional classroom style is used. Staff improvements, sustainability, staff retention, and interviews expressed mixed attitudes about this open improved patient experience. design style. Noise between classrooms is a problem; Ulrich et al.  reviewed the research literature on however, as with the Philip Merrill Environmental EBD healthcare design. Their overall ﬁndings indicated Center, there was satisfaction with the feeling of com- the importance of improving patient outcomes munity between the grade levels . What has not through a range of design characteristics including been sufﬁciently studied at the school is the potential single-bed rooms, effective ventilation systems, good interference with student concentration in a school acoustical environments, increased views of nature, with an open ﬂoor plan such as is used in this school. improved daylighting and interior lighting, better ergo- The use of the lower partitions in the lower grade levels nomic design, acuity-adaptable rooms, and improved is actually the converse of what is needed for optimum ﬂoor layouts and work settings. A number of signiﬁcant acoustical performance for learning. Younger children results were found by optimization of environmental in K-2 grades require a higher signal-to-noise ratio measures through the design process. (clearer voices in a quieter environment) since they EBD can help eliminate hospital-acquired infec- need to be able to carefully listen to develop the ability tions through better control of the three most signiﬁ- to discriminate among minor differences in words, cant vehicles for transmission: air, contact, and water. which is extremely difﬁcult in noisy environments . The most important design measures for infections controls are: (1) effective air quality control measures Application to Healthcare Facilities during construction and renovation using high- Hospitals are embracing evidence-based health care efﬁciency particulate air ﬁlters (HEPA) ﬁltration and design for the promotion of therapeutic, supportive, installation of barriers isolating construction areas and efﬁcient environments. EBD is undertaken to (minimize airborne transmission); (2) installation develop appropriate solutions to design problems and use of alcohol-based handrub dispensers at the and unique situations in order to improve the organi- bedside and other accessible locations (minimize con- zation’s clinical outcomes, economic performance, tact transmission); (3) easy to clean ﬂoor, wall, and
Indoor Environmental Quality and Health Improvement, Evidence-Based Design for 315furniture coverings (minimize contact transmission);(4) water system maintained at proper temperatureswith adequate pressure to minimize stagnation and back-ﬂow (minimize waterborne transmission); and (5) sin-gle-bed rooms with private toilets for better patientisolation (minimize airborne and contact transmission). Medical errors may be reduced through control ofseveral environmental factors including noise, light,and acuity-adaptable single-patient rooms. Noise,both as unacceptable background and episodic inter-ruptions, is responsible for loss of concentration,slower learning, and poor memorization. Additionallyexcessive noise adversely impacts patient recovery by Indoor Environmental Quality and Health Improvement,increasing stress and interrupting sleep. Lighting levels Evidence-Based Design for. Figure 5impact task performance, which in a hospital may Acuity-adaptable, well-lit hospital rooms improve patientresult in transcription errors . Conversely, better care and staff satisfactionlighting and daylighting design results in improvedpatient care and outcomes, staff satisfaction,safety, and decreased operational costs . The acu- Reduction in ambient noise levels has been shownity-adaptable rooms have adequate square footage in through EBD studies to improve patient sleep andthe room to accommodate several clinical activities reduce patient stress [51, 52]. For example, studieswithout moving the patient, well-deﬁned zones for have shown reduced wound healing with exposure topatient care activities, strategic placement of noise, primarily attributed to increased levels of stresshandwashing sink and handrub dispensers, convenient [53, 54]. EBD strategies that are applicable to noiseaccess to medical supplies, headwalls designed with control in hospitals include single-patient rooms, useadequate critical care services, maximum patient visi- of high-performance sound absorbing materialsbility, and patient lifts to ease strain on staff. Another (although these must be easily cleanable), reduceddesirable feature is a family zone so that a visitor is able noise from carts in the hallways, and noiseless pagingto stay with the patient comfortably  (Fig. 5). systems. Studies are showing that patient pain levels and EBD has led to improvements in staff workspacelength of hospital stays can be reduced by exposure to design as well as in patient care. EBD reveals that staffnature and exposure to higher levels of daylight . workspace needs to be designed with closer alignmentWalch et al.  found that spinal surgery patients in to work patterns to improve staff satisfaction, produc-bright daylight lit rooms required 22% less opioid- tivity, and reduce stress reduction, which in turn willequivalent analgesic medications than those in rooms improve patient outcomes . Potential design fea-without the bright daylight. Beauchemin and Hays  tures may include decentralized nursing stations, morefound that myocardial infarction patients in bright efﬁcient layouts that allow staff interaction withdaylight lit rooms had shorter hospital stays of at least patients and family members, and decentralized supplya day shorter. Ulrich  showed that surgery patients locations. Early EBD studies also reveal that the loca-with views of nature had reduced hospital stays and tion of family members near the patients may alsoused lower levels of pain medicine. EBD reveals that improve patient outcomes and reduce hospital stayproviding patients with high levels of daylight and lengths .views of nature (even if only pictures of nature if accessto actual outdoor views are not possible) offers an Economic Performanceopportunity to reduce patient pain medicine use andlength of hospital stays, improving overall patient Salaries and worker beneﬁts generally exceed energyoutcomes. costs by approximately a factor of 100 . Healthy,
316 Indoor Environmental Quality and Health Improvement, Evidence-Based Design for high-performance sustainable buildings that are based employee per year in 2003. The CBPD went on and on EBD principles have a strong potential to have linked the cost of several speciﬁc health conditions and positive economic performance, as long as the EBD illnesses to IEQ (colds, headaches, respiratory illnesses, design principles meet the organizational and health musculoskeletal disorders, and back pain), which needs of the users as well as sustainable design princi- account for approximately $750 of the $5,000 annual ples. Therefore, a signiﬁcant potential exists for busi- costs per employee – 14% of all annual health insurance nesses and building owners to employ EBD principles expenditures. These direct costs would be additionally that improve worker performance, improve health, multiplied by the indirect costs of lost productivity. reduce health insurance costs, and reduce absenteeism. The results from employing BIDS provide the impetus Heerwagen  examined the range of beneﬁts of to demonstrate the ﬁnancial beneﬁts of using EBD to green building features and attributes in buildings. She design better building environments. found that Fisk and Seppanen  demonstrated a beneﬁt- cost ratio as high as 80 and an annual economic beneﬁt ● Green buildings are relevant to business interests as high as $700 per person when measures are made to across the full spectrum of concerns, from port- improve indoor temperature control and increased folio issues to enhanced quality of individual ventilation rates based on a review of the existing workspaces. literature of the health linkages between temperature ● Outcomes of interest that research should address control and increased ventilation rates. Table 1 shows include workforce attraction and retention, quality the estimated productivity gains as a result of four of work life, work output, and customer categories of sources. relationships. ● Green buildings can provide both cost reduction Application to Other Types of Facilities beneﬁts and value added beneﬁts. ● The beneﬁts are most likely to occur when the The in-depth studies to support EBD in healthcare building and organization are treated as an inte- settings are readily adaptable to other types of facilities, grated system from the initiation of the design particularly K-12 schools, including methods for infec- process, as in Evidence-Based Design approaches. tion control, better lighting, access to views and day- lighting, improved acoustical performance, interior The Carnegie Mellon Center for Building Perfor- workspace layouts, and community design. The appli- mance and Diagnostics (CBPD) and the Advanced cation of EBD in conjunction with sustainable design Building Systems Integration Consortium have devel- should result in optimal facilities for learning, oped a decision support tool (The Building Investment healthcare, and work with maximum emphasis on Decision Support Tool – BIDS) to enable building human and ecological health as well as economic decision makers to calculate returns on investments in performance. high-performance building systems and to advance the understanding of the relationship between land use and Schools buildings and health . BIDS is based on a collection of building case studies as well as laboratory and sim- The impact of environmental design on the educational ulation study results to statistically link the quality of performance of students in the UK was investigated by buildings. BIDS uses “soft” and hard life-cycle costs to Edwards . In this study, Edwards investigated if calculate the return on investment. The diverse build- “green” schools provide teaching and learning beneﬁts ing-related costs in the USA, including salaries and beyond those in conventional schools, and what aspects health beneﬁts, technological and spatial turnover, of classroom design appear to be most critical in rent, energy, and maintenance costs, normalized in improving enhanced educational performance. Green dollars per person per year, are shown in Fig. 6. schools were deﬁned as being resource efﬁcient partic- Using statistics from the Bureau of Labor Statistics, ularly in terms of energy use; healthy both physically the CBPD  calculated that the average employer and psychologically; comfortable, responsive, and ﬂex- health insurance cost was approximately $5,000 per ible; and based on ecological principles. In the study of
Indoor Environmental Quality and Health Improvement, Evidence-Based Design for 317 45000 $5,300 Turnover3 40000 $765 (1.7%) Abseenteism4 35000 $244 Lower Respiratory5 $101 Asthma6 30000 $95 Allergies6 $ per person per year $92 Back Pain7 $73 Headaches6 $68 Cold8 Potential Benefits of 25000 $17 MSD9 Quality Buildings $45,000 $19 Throat Imitation6 Salary1 Worktime $18 Eye Irritation6 20000 $18 Sinus Conditions6 Loss 15000 $5,000 Health1 $226 Interior Systems $70 Utility Central Systems $62 Roads and Grounds 10000 $18,500 $1,000 Connectivity $36 External Building Benefits1 (Forrester Group) $73 Process and Environment $10,000 Systems 5000 12.5% Technology Productivity2 $3,200 $450 $412 $200 Rent/Mortgage10 Energy11 FM12 Churn13 0 Salary Benefits Technology Rent/Mortgage Energy FM ChurnIndoor Environmental Quality and Health Improvement, Evidence-Based Design for. Figure 6The true cost of least-cost buildings in the USA (US baselines from CMU BIDS) Indoor Environmental Quality and Health Improvement, Evidence-Based Design for. Table 1 Estimated potentialproductivity gains  Potential US annual savings orSource of productivity gain Potential annual health benefits productivity gain (1996 US $$)Reduced respiratory illness 16–37 million avoided cases of common $6–14 billion cold or influenzaReduced allergies and asthma 8–25% decrease in symptoms within $1–4 billion 53 million allergy sufferers and 16 million asthmaticsReduced sick building syndrome Health symptoms experienced frequently at $10–30 billionsymptoms work by 15 million workersImproved worker performance from Not applicable $20–160 billionchanges in thermal environment andlighting54 schools built between 1975 and 1995, it was dem- teacher satisfaction with the greatest impact on elemen-onstrated that there is relationship between design, tary schools. Beneﬁts were greater in the newer schoolsenergy conservation, and educational performance. with higher levels of ventilation. Absenteeism wasOverall the study demonstrated that green schools reduced in the green schools. The student performanceresulted in enhanced student performance and greater improvement appeared to be particularly related to the
318 Indoor Environmental Quality and Health Improvement, Evidence-Based Design for level of daylight in the classroom, but also the level of conservation followed by providing improved IEQ and ventilation, the temperature control, and noise level connections to nature, reﬂected in energy and atmo- controls. sphere, IEQ, and materials and resources gains. Better Elzeyadi  conducted a study to develop the IAQ, based on the meta-analysis, was found to posi- Green Classroom Toolbox with green design guidelines tively impact occupants’ performance in a range of for retroﬁtting existing educational spaces. The guide- 5–20% improvement. This included reduced illnesses, lines are based on carbon neutrality metrics and stu- both chronic and acute, and improved performance on dent achievement metrics, developed from a meta- testing. Improved temperature control was found to analysis of reported studies and energy modeling sim- improve student performance in the range of 3–10%. ulations. The guidelines center on best practices that Access to views and daylighting improved student per- increase productivity, comfort, and health of students formance in the range of 5–20%. This study emphasizes in retroﬁtted classrooms; facilitate integrated design the need for evidence-based design guidelines for and cooperation between designers; reduce environ- schools, especially to focus on improving IAQ, mental impacts and move toward carbon neutrality improved temperature control, and access to views environments in schools; and are a model for future and daylighting. The manner in which the study was replication and dissemination. The strategic categories conducted simulates the evidence-design process – relevant to building professionals are based on the interaction between the designers and the users, study- USGBC LEED criteria (1) energy and atmosphere ing best practices and strategies in other successful (envelope, lighting, HVAC, and ventilation); (2) mate- facilities, and implementing the practices expected to rials and resources (site construction, structural, and have the most positive impact based on all of the nonstructural); (3) environmental quality (IAQ, com- stakeholders needs. fort, and acoustics); (4) sustainable sites (density, light pollution, and transportation); and (5) water and waste Office Buildings and Other Types of Facilities (building ﬁxtures, landscaping, and recycling). Elzeyadi’s method examined the facility as a whole The Academy of Neuroscience for Architecture has system. He used a framework that treated the students applied evidence-based design practices to ofﬁce build- and the school environment as interdependent ele- ing design – focusing on the previously enumerated ments of a system. The system is comprised of “people” parameters (1) air quality, (2) thermal comfort, (3) spa- and “buildings” on the macro-scale and “buildings” tial comfort, (4) collaborative or teamspace, (5) visual and “environment” on the megascale. This study comfort, (6) workstation comfort, (7) lighting quality, resulted in three primary decision support tools of (8) noise control, and (9) security. In their ofﬁce evidence-based guidelines to help architects, school building study , conducted via post-occupancy designers, and school/school system staff to make questionnaires, it was found that the ofﬁce design informed decisions for implementing green retroﬁt features that support security, wayﬁnding, and feeling measures in classrooms. The ﬁrst tool is a check list of part of a cohesive organization created increased best practices compiled from focus groups and inter- satisfaction and “workability” (considered to be views of affected and interested parties. The second tool neuro-environmental factors) among the employees is a prioritization guide that provides a comparative over their previous ofﬁce space. This was hypothesized analysis and ranking of the best practices list (in Tool 1) to result in reducing stress, improving attention, focus, based on their impacts on building energy consump- and mood. The ofﬁce space design features included tion and carbon emissions. The third tool is a meta- a centralized three-story open stairway connecting analysis guide that links the Tool 1 best practices to the three ofﬁce ﬂoors, providing a naturally mapped their impact on student and staff health and perfor- sense of place, a “public square” housing centralized mance in schools. All of the tools were based on the communications and meeting areas, a main entry area, speciﬁc climates and school typologies of the Paciﬁc centralized lunchroom, well-labeled directional sign- Northwest in the USA. The primary reason found for age, and use of porcelain tile paving across primary adoption of the best practices in schools was energy transit areas.
Indoor Environmental Quality and Health Improvement, Evidence-Based Design for 319 The Academy of Neuroscience for Architecture  sustainability. These metrics must consider the entirealso conducted a limited intervention study exploring system in the occupied setting and not a just a singlethe potential applications of neuroscience concepts unit of the system. Metrics in speciﬁc will greatly aid inand evidence-design based methods to correctional providing the necessary parameters for effective EBDfacilities. The speciﬁc focus topics were (1) daylight studies in a wide range of buildings.and views, (2) exposure to nature, (3) space size, In the future, disparities between sustainable design(4) ambient noise levels, (5) color, and (6) environmen- practices and EBD will need to be resolved. Manytal design features and their impact on inmate–staff practices are fully concurrent, but there are still areasrelationships – reducing stress and aggressive behav- where there is conﬂict, such as lack of acoustical satis-iors. The overall goal of the study was to develop faction in open ofﬁce planning and the potential energyevidence-based design decisions for correctional set- costs of higher rates of ventilation for improved healthtings and operations. The results of this study seemed and productivity/learning.to indicate that views of nature was the most effective EBD takes the ﬁrst step in rigorous research ofmeasure of stress reduction, even if they were only “real” buildings by actively engaging in feedbackprojected nature views on a wall. through occupant questionnaires, and pursuing multi-conﬁguration studies (in the form of layout or building system variations) or multi-building studiesFuture Directions for comparative evaluation by end users. The lack ofIt is critical that EBD be applied much more widely consistent feedback from building occupants and man-across the spectrum of buildings. EBD has agers in the building design community has led for fara tremendous potential to set a new paradigm for too long to anecdotal design decision making, either indesigning healthy, sustainable buildings, by including the form of untested shifts (such as open classrooms)the building managers and occupants as a central player or a dogged commitment to the status quo. EBD isin the entire system’s resolution of ecological and an invaluable step forward, employing a range ofhuman health. post-occupancy tools – both qualitative and quantita- Even in the limited time that evidence-based design tive – to develop design innovations for human andhas been embraced, the data demonstrate important environmental and economic beneﬁt. EBD does notshifts for the building design and management com- eliminate the need for controlled experimentation,munity. For example, the need for increased ventilation both in the lab and in the ﬁeld, to advance innovationsrates signiﬁcantly above those currently being used in in building materials, components, and systems designthe majority of buildings demands the development and operation.and implementation of innovative solutions thatsimultaneously meet reduced energy usage and cost. Summary/ConclusionsThese include systems that separate ventilation andthermal conditioning, and new HVAC system types, The use of Evidence-Based Design to improve the IEQsuch as underﬂoor air distribution and chilled beams. in buildings has the potential to signiﬁcantly impactThese also include improvements in system mainte- the total health, productivity, learning, operationalnance, such as the application of the ASHRAE Indoor efﬁciency, and economic performance of a facility andAir Quality Procedure (IAQP) employing gaseous its occupants. To begin with, a wide variety of studiesphase ﬁltration to aid in air cleaning so that the venti- have shown the importance of a connection to naturelation level can be reduced. Ongoing research in more through access to views and daylighting to reduceeffective technologies and systems management is stress, improve patient outcomes, improve health, andcritical. increase productivity. In the available literature, this Future research must also include the development connection to nature may be the most importantof protocols and metrics to accurately and realistically design feature for overall impact studied to date.measure human impact improvements in health and Secondly, an improved, innovative ventilation systemproductivity/learning, operational efﬁciencies, and has been shown to be critical to improving health and
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