An investigation of the use of health building notes by UK healthcare building designers Sue Hignett a, * , Jun Lu b,1 a Healthcare Ergonomics and Patient Safety Research Unit (HEPSU), Department of Human Sciences, Loughborough University, Loughborough, Leicestershire LE11 3TU, UK b Department of Civil and Building Engineering, Loughborough University, Loughborough, Leicestershire LE11 3TU, UK article info Article history: Received 4 May 2007 Accepted 25 April 2008 Keywords: Hospital design Architecture Design culture User participation Evidence-based medicine abstract Building design in the healthcare industry presents a complex architectural challenge. This paper reports a qualitative study to investigate the use of building design guidance by healthcare architects and planners in the United Kingdom. Sixteen architects, healthcare planners and facilities managers partic- ipated in 11 group and individual interviews. The data were analysed using NVivo2, resulting in three main themes: changes in the design culture over 20 years for the context of guidance use; quality of the evidence base to support the guidance; and future guidance needs to include patient expectations, new building techniques and generic room templates. The use of guidance was variable, with some partici- pants seeing a clear role for new (more standardised) guidance in the future, whereas others were more concerned about loss of design freedom. Two clear roles for ergonomics were identified to: (1) facilitate the participation of patients and clinicians in the design process; and (2) generate new research evidence with respect to spatial requirements for clinical activities to support standardisation. These recom- mendations pertain specifically to healthcare facility design for the National Health Service in the UK. Ó 2008 Elsevier Ltd. All rights reserved. 1. Introduction In the early 1980s the Department of Health and Social Security (DHSS) developed an ergonomic database to act as guidance in the design of new hospitals and the adaptation of old buildings. It has been re-issued at regular intervals over the last 50 years as part of Health Building Notes (HBNs) (Ministry of Health, 1961; NHS Estates, 2005). The aim of the database was to produce a more efficient planning of space by encouraging those involved in hos- pital design to think in terms of the relationship between a user and a particular component and other components located within a room with respect to the critical minimum space required for a wide variety of tasks in different working environments (De- partment of Health and the Welsh Office, 1986). The DHSS hoped that the use of data sheets would ensure good relatively stan- dardized working conditions (Hilliar, 1981; Stanton, 1983). The National Health Service (NHS) is the largest single health- care provider in the world. It was established in 1948 and provides comprehensive health care to the entire population such that ‘every man, woman and child can rely on getting all the advice and treatment and care they may need in matters of personal health; that what they shall get shall be the best of medical and other facilities available; that their getting these shall not depend on whether they can pay for them or any other factor irrelevant to the real need’(Webster, 2002). By 2005 there were over 600 NHS Trusts providing a range of primary care, acute, mental health and ambulance services throughout the UK (Davies, 2004). The complexity of the organisation and changes in the capital funding, with private finance initiative schemes since 1997, add to the challenges for both the healthcare building de- signers and the guidance writers. For many years there have been criticisms of both the design of hospitals ‘the mistakes at one hospital are repeated in others’ and the construction process ‘taking years to build, costs escalating, leaking roofs, cladding falling off’(Smith, 1984). It has been said that ‘few, if any other industries, have been subjected to so much piecemeal and uncoordinated regulation. Hardly any aspect of hospital operation – from the width of the corridor to the number of fire extinguishers to the method of cost funding and accountancy and the overtime payment of the orderly – escapes the scrutiny of some public official’(Moran et al., 1990). For example, the National Audit Office (2005) identified that at least seven agencies were issuing guidance relating to patient safety, including Medicines and Healthcare Products Regulatory Agency, Health Protection Agency, NHS Litigation Agency, NHS Es- tates, National Patient Safety Agency, Health and Safety Executive, Healthcare Commission as well as individual hospital policy. The level of guidance has produced duplication and redundancy with, * Corresponding author. Tel.: þ44 1509 223003; fax: þ44 1509 223940. E-mail addresses: S.M.Hignett@lboro.ac.uk (S. Hignett), J.Lu2@lboro.ac.uk (J. Lu). 1 Tel.: þ44 1509 223003; fax: þ44 1509 223940. Contents lists available at ScienceDirect Applied Ergonomics journal homepage: www.elsevier.com/locate/apergo 0003-6870/$ – see front matter Ó 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.apergo.2008.04.018 Applied Ergonomics 40 (2009) 608–616