BPR Lab

BPR Labs

What is Bioethics Peer Review?

Bioethics Peer Review (BPR) is a formal evaluative process for long-term care and nursing home design. It is modeled on clinical ethics consultation and adapted for use in the planning, design, and development of healthcare environments.

Healthcare buildings function as healthcare interventions. Decisions about layout, circulation, visibility, materials, and spatial relationships can mitigate or exacerbate risks such as falls, delirium, behavioral symptoms of dementia, infection, and staff burnout. Yet unlike clinical interventions, design decisions are rarely subjected to systematic ethical or clinical review.

BPR was developed to address this gap.

The problem BPR addresses

Advances in evidence-based design have demonstrated clear relationships between the built environment and health outcomes for older adults. However, incorporation of this evidence into long-term care design has lagged. Design decisions are often governed by regulatory minimums, cost constraints, and operational convenience rather than by a holistic understanding of resident wellbeing, safety, and what matters most to older adults.

Once built, these decisions persist for decades.

BPR introduces a mechanism for structured ethical and clinical scrutiny at a point when meaningful change is still possible.

The Bioethics Peer Review model

BPR adopts the structure of clinical ethics consultation and applies it to long-term care design. Like ethics consultation, it is:

  • Multidisciplinary

  • Case-specific

  • Values-focused

  • Advisory rather than prescriptive

The process is explicitly aligned with an adapted geriatric framework: 5M+1.

BPR 5M+1 Process Elements

The 5M+1 framework for geriatric design

BPR evaluates design proposals using six domains:

  • Mind – cognition, delirium risk, dementia, sensory processing

  • Mobility – ambulation, fall risk, wayfinding, independence

  • Medications – medication safety, storage, administration workflows

  • Multi-complexity – comorbidities, acuity, care transitions

  • Matters Most – dignity, autonomy, identity, meaningful life

  • Multi-Stakeholder – family, staff, administrators, community

Each domain can be positively or negatively affected by the built environment. BPR uses empirical evidence and ethical analysis to surface these relationships and the value tensions they create.

How the BPR process works

Bioethics Peer Review unfolds through an iterative, consultative process:

  1. Clarify stakeholder values and goals
    Including residents, families, staff, operators, and health systems.

  2. Identify value tensions in the design
    For example: safety vs autonomy, visibility vs privacy, efficiency vs dignity.

  3. Apply relevant evidence and ethical frameworks
    Drawing on geriatrics, architecture, public health, ethics, and operations.

  4. Produce action-guiding analysis
    Highlighting risks, tradeoffs, and ethically defensible alternatives.

  5. Iterate with stakeholders
    As designs evolve and constraints change.

The output is typically annotated design drawings and structured feedback rather than abstract recommendations.

What Bioethics Peer Review is—and is not

BPR is:

  • Advisory

  • Evidence-informed

  • Values-explicit

  • Designed to support better decision-making

BPR is not:

  • A regulatory review

  • A compliance checklist

  • A substitute for architectural or engineering expertise

  • A mandate for specific design outcomes

Its purpose is to make implicit values explicit and to ensure that known clinical and ethical considerations are meaningfully integrated into design decisions.

Pilot applications and feasibility

Bioethics Peer Review has been piloted in two large long-term care facility projects. Informal feedback from health system leaders and design professionals suggests that the process is feasible, decision-relevant, and fills a gap not addressed by existing planning or regulatory mechanisms .

Who Bioethics Peer Review is for

  • Health systems planning long-term care facilities

  • Long-term care operators and administrators

  • Architects and design teams working in healthcare

  • Public agencies and funders evaluating LTC proposals

The BPR Core Research Team

We have the pleasure and privilege of collaborating with individuals, other research teams, healthcare institutions, universities and funding agencies to advance our work. Throughout those valuable partnerships, our core team members each bring unique skills and perspectives to the work.

Bioethics Peer Review

William J. Hercules, MArch
Healthcare architect with expertise in evidence-based design and systems-level infrastructure.

Diana C. Anderson, MD, MArch
Physician–architect specializing in healthcare design, ethics, and long-term care environments.

Stowe Locke Teti, MA, HEC-C
Clinical ethicist specializing in empirical ethics, consultation models, and decision-making frameworks.

David A. Deemer, MD, MA
Physician ethicist focused on organizational ethics, social connection, and care environments.

Portfolio of Research, Interdisciplinary Collaborations, and Advocacy

The Bioethics of Built Space ASBH Annual Conference Presentation

UT Southwestern Grand Rounds: Exploring the Untapped Nexus of Ethics and Health Facility Design

Section

AIA Conference: Architecture and Wellbeing

Ethics and Conscionable Research

Impactful Deisgn is Always an Intervention

Section

Contact / engagement

Interested in Bioethics Peer Review?
We welcome inquiries from organizations exploring its application to long-term care design projects.

Bill@wjh-health.com

diana.anderson@dochitect.com

stoweteti@gmail.com

daviddeemermd@gmail.com

(17 reads, 2 reads today)