7.2 Step 1: Defining Evidence-Based Vision, Goals & Objectives

Step 1: Defining Evidence-Based Vision, Goals & Objectives

Core Principle: In the Center for Health Design (CHD) 8-Step Evidence-Based Design (EBD) Process, Step 1: Define Evidence-Based Goals and Objectives establishes the strategic, clinical, and operational foundation for the entire capital project. Rather than treating an architectural project as an exercise in aesthetic styling or departmental square-footage allocation, EBD positions the physical built environment as an active, therapeutic, and operational intervention engineered to optimize quantifiable clinical, financial, and human outcomes.

Capital healthcare projects represent multi-million or multi-billion dollar investments with lifespans spanning 30 to 50 years or more. Historically, healthcare organizations initiated architectural planning by asking: "How many beds do we need, how many square feet can we afford, and what should the exterior facade look like?" Evidence-Based Design fundamentally upends this paradigm. In Step 1, the multidisciplinary planning team asks: "What clinical, operational, and financial outcomes must this organization achieve, and how can the physical environment be deliberately engineered to produce those results?"

Without establishing rigorous, evidence-informed goals at predesign, subsequent phases flounder: literature searches lack clear queries, design innovations drift into subjective preferences, baseline data collection lacks focus, and post-occupancy evaluations cannot determine whether the building succeeded or failed.

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The 8-Step EBD Process in Context

To understand Step 1, candidates must understand its pivotal role within the CHD's overall 8-Step Evidence-Based Design Process:

1. Step 1: Define evidence-based goals and objectives (Predesign)
2. Step 2: Find sources for relevant evidence (Predesign / Schematic Design)
3. Step 3: Critically interpret relevant evidence (Predesign / Schematic Design)
4. Step 4: Create and innovate EBD concepts (Schematic Design / Design Development)
5. Step 5: Develop a hypothesis (Design Development)
6. Step 6: Collect baseline performance measures (Design Development / Construction Documents)
7. Step 7: Monitor implementation of design and construction (Construction Administration)
8. Step 8: Measure post-occupancy performance results (Post-Occupancy Evaluation)

┌────────────────────────────────────────────────────────────────────────┐
│                     THE 8-STEP EBD PROCESS CYCLE                       │
├────────────────────────────────────────────────────────────────────────┤
│  [STEP 1: Define Goals & Objectives] ◄─── (Vision, Outcomes, Charter)  │
│           │                                                            │
│           ▼                                                            │
│  [STEP 2: Find Sources of Evidence]  ───> (Databases, Grey Literature) │
│           │                                                            │
│           ▼                                                            │
│  [STEP 3: Critically Interpret Evidence] (Appraisal, Validity, Matrix) │
│           │                                                            │
│           ▼                                                            │
│  [STEP 4: Create & Innovate Concepts]───> (Mock-ups, Iterative Design) │
│           │                                                            │
│           ▼                                                            │
│  [STEP 5: Develop Hypotheses]        ───> (Testable Causal Links)      │
│           │                                                            │
│           ▼                                                            │
│  [STEP 6: Collect Baseline Measures] ───> (Pre-occupancy Data Capture) │
│           │                                                            │
│           ▼                                                            │
│  [STEP 7: Monitor Implementation]    ───> (Commissioning, Guard EBD)   │
│           │                                                            │
│           ▼                                                            │
│  [STEP 8: Measure Post-Occupancy]    ───> (POE, Disseminate Knowledge) │
│           │                                                            │
│           └──────────────── feedback loop ─────────────────────────────┘
└────────────────────────────────────────────────────────────────────────┘

Step 1 serves as the North Star for all subsequent steps. If the project team does not clearly define what clinical outcomes it intends to move (e.g., reducing catheter-associated urinary tract infections, mitigating nurse burnout, shortening emergency department length of stay), the team cannot execute an effective literature search in Step 2, cannot formulate testable hypotheses in Step 5, and will have no benchmark against which to collect baseline metrics in Step 6.

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Establishing an Evidence-Based Vision & Strategic Alignment

An evidence-based vision is an aspirational yet actionable articulation of the future state that the physical facility is designed to enable. It synthesizes four foundational drivers:

1. Organizational Mission, Vision, and Values: The facility must tangibly reflect institutional core values. If an organization's mission is "compassionate, patient-centered healing," a building that isolates family members in windowless waiting alcoves violates that mission.
2. Strategic Clinical Priorities: Aligning capital investment with institutional service lines. For instance, if an academic medical center identifies cardiovascular medicine and oncology as its primary regional growth pillars, the facility vision must prioritize specialized hemodynamic workflows, immunocompromised protective environments, and integrated outpatient-inpatient cancer care.
3. Community Health Needs Assessments (CHNA): Under the Affordable Care Act (ACA), non-profit hospitals must conduct triennial CHNAs. Predesign visioning must respond to empirical community demographics, such as high local rates of diabetes, chronic obstructive pulmonary disease (COPD), pediatric asthma, behavioral health crises, or an aging geriatric population requiring extensive bariatric and mobility accommodations.
4. Patient Safety and Regulatory Quality Mandates: Incorporating federal and accreditation quality metrics—such as the Centers for Medicare & Medicaid Services (CMS) Hospital-Acquired Condition Reduction Program (HACRP), Hospital Readmissions Reduction Program (HRRP), and The Joint Commission's National Patient Safety Goals (NPSGs).

Formulating the Vision Statement

A conventional vision statement might state: "To build a premier, cutting-edge 200-bed hospital that serves our metropolitan region with architectural distinction."

In contrast, an EBD vision statement states: "To create a resilient, human-centered healing ecosystem that eliminates preventable patient harm, accelerates physiological recovery through biophilic and circadian optimization, restores clinical caregiver joy and retention, and dynamically flexes to accommodate community health crises over a 50-year lifecycle."

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The Project Vision, Guiding Principles & Vision Keeper (EDAC Study Guide 3)

EDAC study materials describe the project vision as articulating the intentions, direction, and EBD goals and objectives for the project. They also note that the key steps of the EBD process should be implemented through the lens of the project vision, the business case, and the project goals and objectives.

Three Elements That Keep EBD in the Project

To prevent the EBD process from being removed later, the vision should include:

1. Desired outcomes and timelines, including how they might change during the process
2. Documented sponsorship and commitment of executive leaders to the EBD process
3. A statement of the EBD approach

The Vision Keeper

The vision keeper is a person or small team within the project team that keeps the project on point and consistent with the project vision and the organization's overall vision and goals.

Guiding Principles

Guiding principles defined at the start of the project are developed to:

• Set the project goals
• Serve as a planning framework
• Guide the decision-making process

They should be used and checked continuously throughout the project. Later, during design, each design concept is tested against the guiding principles to see how well it addresses the original goals (see Section 10.3).

The Strategic Facilities Plan

EDAC study materials describe a strategic facilities plan that outlines the organization's goals and objectives, the market position driving the need for change, and specific projects that bring the physical environment in line with operational goals. For an EBD project, it should also:

• Translate project goals and objectives into research hypotheses
• Evaluate current practices and establish an operational baseline (collecting data on the current level of performance)
• Determine market positioning, including proposed service offerings
• Identify the context and culture in which the project will be carried out
• Identify research and outcome metrics
• Formulate a research budget and a plan to secure funding

From the Business Plan to Guiding Principles and Design Guidelines

CHD's current exam content outline adds three points about developing the project vision, EBD goals and objectives, guiding principles, and design guidelines:

• The scope and expected outcomes identified in the owner's project business plan must be translated into a description of what the project hopes to accomplish.
• Guiding principles and design guidelines are essential for developing evidence-based design concepts and strategies. Guiding principles state the values and priorities; design guidelines translate them into more specific design direction (for example, "every patient can see the entry to the toilet room from the bed").
• The project vision should be consistent with the corporate strategy and vision and with the owner's project business plan and goals.

The outline then asks the team to document the process and translate the vision, EBD goals, guiding principles, design guidelines, and operations into the functional and space program that becomes the basis of design (Section 7.4).

Being Ready to Pause

Study materials add that, in a time of rapid change, the interdisciplinary team must be prepared to stop and reassess—to revisit information or process based on new information, to reassess assumptions or objectives, or to review the plan entirely—so misunderstandings are caught before anything is built and money is spent.

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Conventional Programming Goals vs. Evidence-Based Objectives

Be able to differentiate conventional architectural programming goals from evidence-based design objectives.

Conventional architectural programming focuses almost exclusively on spatial inputs and physical capacities—gross square footage, departmental room counts, adjacencies, aesthetic finishes, and capital budgets. The building is treated as an inert container.

Evidence-Based Design focuses on systemic outcomes—how the physical arrangement directly alters biological, behavioral, cognitive, and financial indicators. The building is treated as an active clinical instrument.

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Formulating SMART EBD Objectives

To translate broad vision statements into actionable design criteria, many teams use SMART criteria (a general planning tool rather than a CHD-specific requirement). The targets in the examples below are illustrative, not published benchmarks:

• Specific (S): Targets a concrete, unambiguous clinical endpoint, operational process, or patient population (e.g., hospital-acquired Clostridioides difficile infections in the bone marrow transplant unit, rather than "improve hygiene").
• Measurable (M): Quantified using established clinical, financial, or operational metrics (e.g., infections per 1,000 patient days, registered nurse steps per 12-hour shift, decibel levels during night shifts).
• Achievable (A): Realistic and grounded in existing empirical literature and organizational capability (e.g., targeting a 20% to 35% reduction in patient falls based on benchmarked peer-reviewed studies, rather than claiming zero falls will ever occur).
• Relevant (R): Directly tied to organizational strategic priorities, clinical safety mandates, staff wellbeing, or reimbursement incentives (e.g., reducing 30-day readmissions to avoid CMS financial penalties).
• Time-bound (T): Specifies clear pre-occupancy baseline data-collection windows and post-occupancy evaluation intervals (e.g., evaluated at 6, 12, and 24 months post-activation).

┌────────────────────────────────────────────────────────────────────────┐
│                     SMART EBD OBJECTIVE MATRIX                         │
├──────────────┬────────────────────────────┬────────────────────────────┤
│ DOMAIN       │ CONVENTIONAL INPUT PHRASING│ SMART EBD OBJECTIVE        │
├──────────────┼────────────────────────────┼────────────────────────────┤
│ Clinical     │ "Install quiet ceiling     │ "Reduce 30-day ICU         │
│ Safety       │ tiles and sound masking in │ delirium incidence by 25%  │
│              │ the Intensive Care Unit."  │ within 12 months of move-in│
│              │                            │ by maintaining nocturnal   │
│              │                            │ sound levels below 45 dBA  │
│              │                            │ using NRC 0.90 ceilings."  │
├──────────────┼────────────────────────────┼────────────────────────────┤
│ Operational  │ "Provide decentralized     │ "Decrease average RN daily │
│ Efficiency   │ nurse stations outside     │ shift travel distance from │
│              │ patient rooms."            │ 5.2 miles to under 2.8     │
│              │                            │ miles within 6 months of   │
│              │                            │ occupancy via decentralized│
│              │                            │ supply and charting nodes."│
├──────────────┼────────────────────────────┼────────────────────────────┤
│ Financial    │ "Keep the mechanical HVAC  │ "Achieve full capital      │
│ Return       │ replacement within the     │ payback within 3.5 years   │
│              │ $4.5 million MEP budget."  │ through a 40% reduction in │
│              │                            │ surgical site infections,  │
│              │                            │ saving $28,000 per avoided │
│              │                            │ infection episode."        │
├──────────────┼────────────────────────────┼────────────────────────────┤
│ Human /      │ "Design an attractive,     │ "Increase HCAHPS 'Quiet at │
│ Perceptual   │ comfortable inpatient      │ Night' top-box scores from │
│              │ nursing unit."             │ the 42nd percentile to the │
│              │                            │ 85th percentile within     │
│              │                            │ 12 months post-occupancy." │
└──────────────┴────────────────────────────┴────────────────────────────┘

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Multidisciplinary EBD Team Composition

EDAC study materials stress that the project team should be assembled early and be interdisciplinary. In traditional practice, early programming is often conducted in a silo between external architects and hospital facility managers or senior executives. In Evidence-Based Design, the team incorporates a broad coalition of stakeholders from the start of predesign:

1. Executive Leadership (C-Suite)

• Chief Executive Officer (CEO) & Chief Operating Officer (COO): Ensure alignment with long-range strategic vision, institutional brand, and community positioning.
• Chief Financial Officer (CFO): Approves capital allocations and evaluates life-cycle return on investment (ROI), operational savings, and clinical business cases rather than solely policing initial capital costs.

2. Clinical Leadership

• Chief Medical Officer (CMO) & Chief Nursing Officer (CNO): Champion clinical quality, interprofessional collaboration, nursing care models, and patient safety imperatives.
• Frontline Registered Nurses & Care Technicians: Provide indispensable knowledge regarding micro-workflows, physical fatigue, equipment storage frustrations, and real-world clinical workarounds.
• Physicians & Surgeons: Define specialized procedure-room ergonomics, sightlines, technology integration, and interventional adjacencies.

3. Support Services & Operations

• Infection Preventionists (IP): Establish non-negotiable requirements for hand-hygiene sink locations, airborne infection isolation room (AIIR) pressure cascades, clean-to-dirty workflow separation, and antimicrobial material selections.
• Facility Managers (FM) & Environmental Services (EVS): Evaluate long-term maintainability, equipment durability, surface cleanability, HVAC filtration access, chemical compatibility, and waste stream logistics.
• Risk Management & Quality Officers: Ensure compliance with Joint Commission mandates, fire codes, life safety codes, ADA/accessibility guidelines, and liability mitigation.

4. Design & Research Specialists

• EBD Researchers / EDAC Certified Professionals: Guide the research translation process, formulate research hypotheses, identify relevant scientific databases, establish baseline metrics, and design post-occupancy protocols.
• Architects, Planners & Interior Designers: Synthesize clinical evidence into constructible spatial plans, daylighting models, acoustic assemblies, and interior material palettes.

5. Patient and Family Representatives

• Patient & Family Advisory Council (PFAC) Members: Provide the lived experience of vulnerability, identifying anxiety-inducing physical transitions, wayfinding barriers, family overnight accommodation deficits, and dignity violations.

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Developing the Formal Project Charter and EBD Governance

A vision without a governance structure inevitably evaporates when project budgets encounter financial pressure. Therefore, Step 1 culminates in the authoring and executive signing of a formal Project Charter and the establishment of an EBD Governance Framework.

Core Elements of an EBD Project Charter

1. Executive Problem Statement & Business Justification: Articulates the clinical and operational shortcomings of the existing facility (e.g., cramped 1970s semi-private rooms driving elevated HAI rates and severe nurse turnover).
2. Evidence-Based Vision Statement: Defines the overarching transformational intent of the capital project.
3. Quantifiable SMART Objectives: Formally lists the agreed clinical, operational, financial, and perceptual metrics, establishing explicit pre-occupancy baseline targets.
4. Project Scope and Boundary Conditions: Delineates what is included and excluded from the capital initiative.
5. Research & POE Resource Allocation: Earmarks budget for literature retrieval, mock-up testing, baseline data capture, and post-occupancy evaluation, consistent with the research budget and funding plan in the strategic facilities plan.
6. Multidisciplinary Governance Structure: Outlines clear roles, reporting hierarchies, and decision-making authority.

┌────────────────────────────────────────────────────────────────────────┐
│                     EBD GOVERNANCE STRUCTURE                           │
├────────────────────────────────────────────────────────────────────────┤
│                    EXECUTIVE STEERING COMMITTEE                        │
│               (CEO, CFO, CNO, CMO, Board Member, Lead Architect)       │
│               • Fiduciary oversight, strategic approval, charter guard │
└───────────────────────────────────┬────────────────────────────────────┘
                                    │
                                    ▼
┌────────────────────────────────────────────────────────────────────────┐
│                       CORE EBD PROJECT TEAM                            │
│         (Project Director, Lead Architect, Lead EBD Researcher,        │
│          Nurse Champion, Facilities Director, Patient Advocate)        │
│         • Day-to-day coordination, milestone tracking, research link   │
└───────────────────┬────────────────────────────────┬───────────────────┘
                    │                                │
                    ▼                                ▼
┌──────────────────────────────────────┐ ┌───────────────────────────────┐
│    CLINICAL USER WORKING GROUPS      │ │   EBD RESEARCH & POE TASKFORCE│
│  (Physicians, Bedside RNs, EVS, IP,  │ │  (EBD Researchers, Biostat,   │
│   Pharmacy, Imaging, Transport)      │ │   Quality Analysts, Academics)│
│  • Functional flow, mock-up review   │ │  • Baseline logs, POE studies │
└──────────────────────────────────────┘ └───────────────────────────────┘

Guarding EBD Intent Against "Value Engineering"

One of the most hazardous phases in any healthcare capital project is Value Engineering (VE). In conventional practice, when schematic cost estimates exceed initial budgets, general contractors and cost estimators present a list of "cost deductions" to cut capital expenses.

In conventional projects, high-performance acoustic ceiling tiles (NRC 0.90), decentralized charting alcoves, oversized patient room windows, circadian lighting systems, and dedicated hand-hygiene sinks are routinely slashed because they carry higher upfront material costs.

[!CAUTION]

EXAM TRAP: The Role of the Project Charter During Value Engineering

An EBD Project Charter is specifically designed to prevent short-sighted value engineering. When a contractor proposes cutting decentralized nursing alcoves or sound-absorbing ceilings to save $450,000 in capital costs, the EBD governance committee references the Charter:

"Cutting these acoustic ceilings undermines our objective to reduce nighttime noise and improve our HCAHPS quietness results. Our business case estimated recurring costs from sleep disruption and longer stays that exceed the one-time savings, so we need to rerun that analysis before we agree." (Hypothetical example.)

In EBD, any proposed design modification during VE must undergo an evidence impact analysis to evaluate its downstream consequences on clinical outcomes, regulatory penalties, and operating expenses.