The success of a health facility can be judged by its ability to satisfy the needs of its many and diverse stakeholders. These include patients, their friends and families, clinicians, other staff members, and health service managers. Further, in considering the design, development and procurement of health facilities, the particular perspective of healthcare funders who rely on such facilities to underpin and support their business activities must also be acknowledged. Healthcare is an increasingly complex industry with increasing demands from changing demographics, increasing consumer expectations plus new developments in technology and care delivery. Designing health facilities to support such demands requires careful and structured approaches to briefing and design so that value for money is achieved, consistently high standard facilities achieved and disparities in quality reduced. Design guidelines are a tool used to enforce this rigour. This paper examines the interaction of stakeholders and ‘evidence’ in the governance and decision‐making processes that accompany the development of evidence‐based health facility guidelines for the design of hospital projects in Australia and New Zealand.