Indoor environmental quality (IEQ) encompasses factors like air quality, thermal comfort, lighting, acoustics, and more that impact occupant health and well-being. Evidence-based design (EBD) bases building decisions on credible research to achieve optimal outcomes. EBD has primarily been applied to healthcare, where it reduces costs and lengths of stay. Effective EBD considers factors like ventilation, temperature, noise, and lighting that research links to stress, productivity and health. The design must balance health, sustainability and efficiency.

1. 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 result
CHARLENE W. BAYER in a healthy indoor environment for building
Georgia 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 improving
Article Outline health services.
Glossary Definition of Evidence-Based Design
Definition of Evidence-Based Design
Introduction Evidence-based design (EBD), as defined by the Center
Application to Healthcare Facilities for Health Design [1], is “the process of basing deci-
Application to Other Types of Facilities sions about the built environment on credible research
Future Directions to achieve the best possible outcomes.” EBD is an
Summary/Conclusions approach to facilities design that treats the building
Bibliography 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 to
AIA (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 the
Cfm (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 [2]. 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 the
HVAC (heating, ventilation, and air-conditioning World Health Organization (WHO) [3] 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 or
IAQ (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 2013
Originally published in
Robert A. Meyers (ed.) Encyclopedia of Sustainability Science and Technology, # 2012, DOI 10.1007/978-1-4419-0851-3

2. 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 [4]. 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 [7]. 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 [8]
● 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 [5] 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 [6] 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

3. 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 support
Indoor Environmental Quality and Health Improvement, Evidence-Based Design for. Figure 1
Rashid and Zimring [6] conceptual framework describing how the physical environment may initiate a process leading to
stress
evidence-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 health
Indoor 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 emissions
the use of low-emitting furnishings and building mate- investigations [21].
rials, designed to meet an iteratively tightening set of Another strategy available for reducing exposures
standards [17–20]. This strategy addresses one of the to airborne contaminants is source control of indoor
most important IAQ determinants that is clearly in the equipment and activities. Office machines, stoves, and
realm of the designer – source control. However, the other appliances that are known to be active pollutant
construction process, including installation sequence generators benefit from the use of local source control
and protection of materials prior to installation, is via the installation of dedicated exhaust fans. The use of
also an important factor to be addressed by the EBD local source control systems needs to be part of the
team. Installation of carpet prior to painting of walls design process and the location of the areas needing
can result in long-term low level emissions of paint dedicated ventilation and exhausts need to be defined
fumes due to adsorption by the carpet and slow early in the design process. The use of well-maintained
reemission into the indoor environment. Key furnish- air cleaners is another strategy that may be appropriate to
ing and material sources that must be specified as selected areas and types of facilities, such as in hospitals.

4. 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. [30] 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 [22]. 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) [32]
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 [23]. 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

5. Indoor Environmental Quality and Health Improvement, Evidence-Based Design for 311
humans, improving accuracy of work performance, privacy include possibly reconsideration of the open
reducing stress and fatigue, and improving patient out- office plan, designing private areas adjacent to the open
comes [32]. Loftness et al. [14] found that improved office area for use in private situations as needed, or
lighting quality design decisions are linked with increasing background noise. A lack of speech clarity
0.7–23% gains in individual productivity. The lighting occurs when the acoustics or a room design deteriorate
quality design ranged from indirect–direct lighting sys- the acoustical communication channel, rendering
tems, higher quality fixtures, and daylighting simula- speech to the intended listener unintelligible, creating
tion. When daylight responsive dimming was communication problems. This is particularly an issue
employed 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 or
with individual health and productivity. Design deci- excessive reverberation. EBD solutions to improve
sions 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 been
shown to result in 3–18% increases in individual pro- Operation and Maintenance
ductivity [14] 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 the
comes). Lighting conditions in classrooms have impor-
facilities lifetime, and EBD feedback on the long-term
tant non-visual effects on students including potentially
integrity and maintainability of the materials, compo-
raising test scores and faster responding on tests [33].
nents or systems. Metrics should be defined during the
design process for the ability to maintain the facility in
Acoustics/Noise Control Acoustics is an area of con-
order to meet health and client economic performance
tinued dissatisfaction in many green buildings [9]. In
needs. These metrics, at a minimum, should include:
a number of projects, the open plan design, large areas
of 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 the
ings 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 furnishings
classified in three categories: excessive noise, lack of ● Frequency, extensiveness, and difficulty to perform
speech 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 materials
emanating from outdoor noise sources that are trans- ● Equipment and furnishings life expectancies
mitted 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 users
noise from other occupants. Acoustical design strate-
Magee [33] 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 cleaning
speech is unintelligible to an unintended listener. The to maintain
worst speech privacy situations are those where the ● Promptly respond and repair minor discrepancies
background noise is very low. In open office plan envi- ● Develop and execute a system of regularly scheduled
ronments, the lack of speech privacy may be a signifi- maintenance actions to prevent premature failure of
cant stressor. Design strategies to help improve speech the facility, its systems, and/or components

6. 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. [34] 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

7. 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 of
has been found to impact productivity and learning in ease of repair, access to cleaning area, and ease of
office buildings and schools. Wargocki et al. [35], in cleaning. Property managers also reported frequently
a 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 maintenance
with 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 the
34.4 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 building
systems need to be designed for easy performance of
Human Factor Impacts/Occupant/Customer
ventilation system maintenance tasks.
Satisfaction on Sustainable Designs
Arditi and Nawakorawit [36] surveyed 211 of the
largest US building design firms to investigate the rela- Many sustainable design strategies reduce the use of
tionship 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, and
which maintenance issues are considered when increase ventilation airflow, particularly when natural
designers specify building materials and service equip- and hybrid ventilation strategies are used. Although
ment; the level of designers’ knowledge in mainte- this may increase satisfaction with daylight and access
nance-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 [37]. This situ-
related matters; the extent to which designers consult ation was encountered in the LEED Platinum certified
property managers and maintenance consultants; the Philip Merrill Environmental Center in Annapolis, MD
relative importance of maintenance issues to other [38]. This facility placed the entire workforce into an
design 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, without
components; and the magnitude and frequency of doors and low partitions for almost all employees
maintenance-related complaints that designers receive (Fig. 3). This allows access to views and daylighting
from clients and tenants. Their findings indicate that for all employees and the occupants’ satisfaction ratings
maintenance consideration follow cost and aesthetics are very high. However, the primary complaints that
issues when designers specify building materials, but remain are lack of privacy, noise, distractions, and
maintenance considerations constitute the number one interference with work concentration. At the same
issue when specifying service equipment. For most time, the occupants rated the views, daylighting, and
firms, 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 for
of cleaning, inspection, repair, and replacement with determining the potential effectiveness of open space
both 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 in
area, and ease of cleaning were ranked by designers to Atlanta, GA, organized in pods, uses four-foot high
be among the least important design factors for build- partitions among lower grade classrooms in each pod
ing 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

8. 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. [43] 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 [41]. 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 [42].
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

9. Indoor Environmental Quality and Health Improvement, Evidence-Based Design for 315
furniture coverings (minimize contact transmission);
(4) water system maintained at proper temperatures
with adequate pressure to minimize stagnation and back-
flow (minimize waterborne transmission); and (5) sin-
gle-bed rooms with private toilets for better patient
isolation (minimize airborne and contact transmission).
Medical errors may be reduced through control of
several 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. Additionally
excessive noise adversely impacts patient recovery by Indoor Environmental Quality and Health Improvement,
increasing stress and interrupting sleep. Lighting levels Evidence-Based Design for. Figure 5
impact task performance, which in a hospital may Acuity-adaptable, well-lit hospital rooms improve patient
result in transcription errors [44]. Conversely, better care and staff satisfaction
lighting and daylighting design results in improved
patient care and outcomes, staff satisfaction,
safety, and decreased operational costs [45]. The acu- Reduction in ambient noise levels has been shown
ity-adaptable rooms have adequate square footage in through EBD studies to improve patient sleep and
the room to accommodate several clinical activities reduce patient stress [51, 52]. For example, studies
without moving the patient, well-defined zones for have shown reduced wound healing with exposure to
patient care activities, strategic placement of noise, primarily attributed to increased levels of stress
handwashing sink and handrub dispensers, convenient [53, 54]. EBD strategies that are applicable to noise
access to medical supplies, headwalls designed with control in hospitals include single-patient rooms, use
adequate critical care services, maximum patient visi- of high-performance sound absorbing materials
bility, and patient lifts to ease strain on staff. Another (although these must be easily cleanable), reduced
desirable feature is a family zone so that a visitor is able noise from carts in the hallways, and noiseless paging
to stay with the patient comfortably [46] (Fig. 5). systems.
Studies are showing that patient pain levels and EBD has led to improvements in staff workspace
length of hospital stays can be reduced by exposure to design as well as in patient care. EBD reveals that staff
nature and exposure to higher levels of daylight [47]. workspace needs to be designed with closer alignment
Walch et al. [48] 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 will
equivalent analgesic medications than those in rooms improve patient outcomes [38]. Potential design fea-
without the bright daylight. Beauchemin and Hays [49] tures may include decentralized nursing stations, more
found that myocardial infarction patients in bright efficient layouts that allow staff interaction with
daylight lit rooms had shorter hospital stays of at least patients and family members, and decentralized supply
a day shorter. Ulrich [50] 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 also
used lower levels of pain medicine. EBD reveals that improve patient outcomes and reduce hospital stay
providing patients with high levels of daylight and lengths [55].
views of nature (even if only pictures of nature if access
to actual outdoor views are not possible) offers an
Economic Performance
opportunity to reduce patient pain medicine use and
length of hospital stays, improving overall patient Salaries and worker benefits generally exceed energy
outcomes. costs by approximately a factor of 100 [56]. Healthy,

10. 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 [57] 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 [58] 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 [56]. 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 [59]. 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 [56] 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

11. 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 Churn
Indoor Environmental Quality and Health Improvement, Evidence-Based Design for. Figure 6
The true cost of least-cost buildings in the USA (US baselines from CMU BIDS) [50]
Indoor Environmental Quality and Health Improvement, Evidence-Based Design for. Table 1 Estimated potential
productivity gains [58]
Potential US annual savings or
Source 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 influenza
Reduced allergies and asthma 8–25% decrease in symptoms within $1–4 billion
53 million allergy sufferers and 16 million
asthmatics
Reduced sick building syndrome Health symptoms experienced frequently at $10–30 billion
symptoms work by 15 million workers
Improved worker performance from Not applicable $20–160 billion
changes in thermal environment and
lighting
54 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 schools
energy conservation, and educational performance. with higher levels of ventilation. Absenteeism was
Overall the study demonstrated that green schools reduced in the green schools. The student performance
resulted in enhanced student performance and greater improvement appeared to be particularly related to the

12. 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 [60] 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 [61], 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.

13. Indoor Environmental Quality and Health Improvement, Evidence-Based Design for 319
The Academy of Neuroscience for Architecture [62] sustainability. These metrics must consider the entire
also conducted a limited intervention study exploring system in the occupied setting and not a just a single
the potential applications of neuroscience concepts unit of the system. Metrics in specific will greatly aid in
and evidence-design based methods to correctional providing the necessary parameters for effective EBD
facilities. 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. Many
tal design features and their impact on inmate–staff practices are fully concurrent, but there are still areas
relationships – 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 energy
evidence-based design decisions for correctional set- costs of higher rates of ventilation for improved health
tings 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 of
measure of stress reduction, even if they were only “real” buildings by actively engaging in feedback
projected 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 studies
Future Directions
for comparative evaluation by end users. The lack of
It 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 far
a tremendous potential to set a new paradigm for too long to anecdotal design decision making, either in
designing 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 is
in the entire system’s resolution of ecological and an invaluable step forward, employing a range of
human health. post-occupancy tools – both qualitative and quantita-
Even in the limited time that evidence-based design tive – to develop design innovations for human and
has been embraced, the data demonstrate important environmental and economic benefit. EBD does not
shifts 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 innovations
rates significantly above those currently being used in in building materials, components, and systems design
the majority of buildings demands the development and operation.
and implementation of innovative solutions that
simultaneously meet reduced energy usage and cost.
Summary/Conclusions
These include systems that separate ventilation and
thermal conditioning, and new HVAC system types, The use of Evidence-Based Design to improve the IEQ
such as underfloor air distribution and chilled beams. in buildings has the potential to significantly impact
These also include improvements in system mainte- the total health, productivity, learning, operational
nance, such as the application of the ASHRAE Indoor efficiency, and economic performance of a facility and
Air Quality Procedure (IAQP) employing gaseous its occupants. To begin with, a wide variety of studies
phase filtration to aid in air cleaning so that the venti- have shown the importance of a connection to nature
lation level can be reduced. Ongoing research in more through access to views and daylighting to reduce
effective technologies and systems management is stress, improve patient outcomes, improve health, and
critical. increase productivity. In the available literature, this
Future research must also include the development connection to nature may be the most important
of 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 system
productivity/learning, operational efficiencies, and has been shown to be critical to improving health and

14. 320 Indoor Environmental Quality and Health Improvement, Evidence-Based Design for
productivity in buildings, of at least 25 L/s per person. 13. Wilkins KK, Wolkoff PP, Knudsen HN, Clausen PA (2007) The
Thirdly, the separation of temperature control from the impact of information on perceived air quality –“organic” vs.
“synthetic” building materials. Indoor Air 17(2):130–134
ventilation system is another important component for 14. Wolkoff PP, Wilkins CK, Clausen PA, Nielsen GD (2006) Organic
improving thermal comfort without compromising compounds in office environments – sensory irritation, odor,
ventilation air delivery. Finally, acoustical control is measurements and the role of reactive chemistry. Indoor Air
one of the most challenging parameters for EBD inno- 16(1):7–19
vation, yet critically needed to achieve occupant satis- 15. Loftness V, Hartkopf V, Gurtekin B, Hansen D, Hitchcock R
(2003) Linking energy to health and productivity in the built
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schools. Rev Environ Health (submitted)
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