Weill Cornell Physician Organization, New York City. Rendering by Polshek Partnership/Ballinger Architects, and dboxstudio (USA)
In 2000, The Center for Health Design's board of directors launched an ambitious research initiative called the Pebble Project. The idea was to engage healthcare providers who were building new facilities or renovating old ones to measure the results of their design innovations and share their data with the industry at large. By doing so, they would create a ripple effect in the healthcare industry and contribute to what was then the relatively unknown science of evidence-based design.

In fact, the Pebble Project was inspired by the Children's Hospital and Health Center in San Diego. In planning to build a new freestanding Children's Convalescent Hospital, Children's had undertaken a comprehensive study of its 30-year-old “convalescent hospital” environment to ascertain the level of family and caregiver satisfaction it inspired. The opportunity to measure the same variables with the same patient population and staff in a new hospital building launched the Pebble Project concept.

(Because of financial constraints, construction of the Children's Convalescent Hospital in San Diego has been delayed for three years, during which time the number of children in this population who can be cared for at home has significantly increased, and the volume of children needing hospitalization has decreased by one-third. Consequently, Children's has decided not to build the original freestanding hospital but to renovate a different part of the hospital for this patient population. It still, however, intends to undertake a comprehensive analysis of the impact of the new environment on families and caregivers.)


Since the initial inspiration provided by Children's, 31 other providers have joined the Pebble Project; two have “graduated,” and one never started its project and dropped out. The remainder range from replacement hospitals to unit renovations to acute care building additions, long-term care facilities, and ambulatory care centers.

Since most of the 28 active provider partners are in the beginning stages of planning and/or data collection, it will be several years before many of them have any results to share. However, three of the first four providers to join the Pebble Project already have completed projects, and some good data have been collected and shared, including:

  • Patient falls are down 75% in a redesigned critical care unit at Methodist Hospital in Indianapolis.

  • Patient satisfaction rose 18% and nurse turnover fell from 23 to 2.8% on a redesigned inpatient unit at the Barbara Ann Karmanos Cancer Institute in Detroit.

  • Nosocomial infection rates have decreased 11% after the new Bronson Methodist Hospital opened in Kalamazoo, Michigan.

While they are waiting for their projects to begin, several other Pebble Project partners have done some test studies and produced interesting data, including:

  • Staff turnover has dropped from 14.1 to 12.5% a year at Parrish Medical Center in Titusville, Florida, since it opened its new hospital in 2002.

  • After installing lifts in patient rooms on two units of an existing facility, annual costs of patient-handling injuries decreased from $365,145 to $993 at PeaceHealth in Eugene, Oregon.

  • Quality of sleep improved from 4.9 to 7.3 (on a scale of 1 to 10), as reported by patients on a renovated patient unit at Saint Alphonsus Regional Medical Center in Boise, Idaho.

Needless to say, the success of the Pebble Project has created a lot of interest in the healthcare and design communities. It attracted the attention of the Robert Wood Johnson Foundation, which funded the development and publication of a research report, “The Role of the Physical Environment in the Hospital of the 21stCentury: A Once-in-a-Lifetime Opportunity,” which is a summary of 600 evidence-based design research studies, including some from the Pebble Project. Since it was published in September 2004, more than 5,000 copies of this report have been downloaded at no charge from The Center for Health Design's Web site. Moreover, several of The Center's board members used Pebble Project data to author an article titled “The Business Case for Better Buildings,” published in the Fall 2004 issue ofFrontiers of Health Services Management, a journal distributed to 1,500 members of the American College of Healthcare Executives. So many additional copies of this issue were ordered that the publisher ran out of inventory (something that rarely happens).

More applications to join the Pebble Project are pending, and The Center for Health Design expects this number to grow to 35 participants by the end of this year, possibly even adding some international partners. Recently, two corporate Pebble Partners, Steelcase and Hill-Rom, were added. Each plans to contribute to the body of research by partnering with other “Pebbles” to conduct studies. And although every provider is working with a reputable healthcare design firm, several design firms, including Hammel, Green and Abrahamson, Inc., (HGA) of Milwaukee and Gresham, Smith and Partners of Nashville, are also paying part of the annual $25,000 fee to participate in the project with their provider clients.

What began as a ripple has clearly become a wave, as more and more providers and their design firms are deciding that they, too, see the value in measuring and documenting the impact of the built environment on healthcare outcomes, satisfaction, safety, and performance. Below is a status report on current Pebble Project provider partners (as of press time), in order of their joining, and a summary of their progress.

Children's Hospital and Health Center, San Diego

Children's, as already mentioned, is renovating part of its existing hospital to replace its aging Children's Convalescent Hospital (the only one in California for children) and still intends to complete a comprehensive analysis of its impact on families and caregivers. The project architect is Anshen+Allen.

Bronson Methodist Hospital, Kalamazoo, Michigan

The redevelopment of Bronson Methodist Hospital (figure 1), which began in 1993, has created a state-of-the-art, easily accessible healthcare campus that brings together inpatient care, outpatient care, and physicians' offices in a patient-focused healing environment. The $181 million project includes a new medical office pavilion (completed in April 2000), an outpatient pavilion (also completed in April 2000), and an inpatient pavilion (completed in December 2000). The project architect was Shepley Bulfinch Richardson and Abbott, Boston; the associate architect was Diekema/Hamann Architects, Kalamazoo, Michigan.

Froedtert Hospital, Milwaukee

This project involves designing well-conceived, efficient nurses' stations (figure 2) to measure outcomes in terms of higher-quality patient care and staff satisfaction. The project architect is HGA, Milwaukee.

Saint Alphonsus Regional Medical Center, Boise, Idaho

Saint Alphonsus (figure 3) is embarking on a $161 million renovation of its Curtis Road campus, expected to be operational in 2008. The concept of “Advanced Healing” is being integrated into every element of the design and culture. A master facility plan for the Curtis Road campus provides for renovation of the main South Tower, a two-story infill between the two existing towers, and a new nine-story tower (including seven floors of patient rooms). The expansion will add approximately 400,000 square feet to the main hospital structure. The project architect is HDR, based in Chicago.

Weill Cornell Physician Organization, New York City

Together with the Weill Medical College, the organization is undertaking an operational planning process as its Pebble Project, as well as building a new ambulatory care building. The objective is to define the guiding principles and operational elements needed to transform the ambulatory patient care experience into a caring environment for all patients, physicians, and staff. The project architect is Ballinger, based in Philadelphia.

Parrish Medical Center, Titusville, Florida

Parrish opened a 210-bed facility in November 2002 that was planned and constructed with patient healing in mind. This new hospital is not only technologically advanced and efficient but also patient-sensitive and provider-friendly. The design firm was Earl Swensson Associates, Inc., in Nashville.

Scott & White Memorial Hospital, Temple, Texas

Scott & White is building a 525,000-sq.-ft. replacement hospital called the Center for Advanced Medicine, expected to be completed in 2006. Its Pebble Project will compare data between the old and new facilities in the following areas: patient satisfaction, employee satisfaction/turnover, outcome measures, cost indicators, patient activity, unit activity, nursing quality, and employee injuries. The project architect is PageSoutherlandPage in Austin, Texas.

Yavapai Regional Medical Center, Prescott, Arizona

Yavapai is planning a new 50-bed hospital in the neighboring town of Prescott Valley that will be completed in 2006. Yavapai plans to compare data from its existing facility on employee turnover, outcomes, lengths of stay, cost per unit of service, waiting times, and patient satisfaction with those data from its new facility. The project architect is Gresham & Beach Architects, Inc., in Tucson.

Charles T. Sitrin Health Care Center, New Hartford, New York

The Charles T. Sitrin Health Care Center plans to create a community that inspires positive recovery outcomes for individuals whose life activities may otherwise be compromised by injury or illness. It will offer independent living opportunities for people wishing to maintain their autonomous lifestyle. In addition, Sitrin will transition its nursing home from an institutional model to small residences where care will be customized to match each resident's needs. Sitrin also intends to become a major training center for the International Paralympic Games and will be the only facility of its kind in the Northeast. No architect has been selected yet.

MD Anderson Cancer Center Ambulatory Clinic Building, Houston

MD Anderson recently opened a 746,300-gross-sq.-ft. Ambulatory Clinical Building that is the first of several clinical buildings planned on the Houston Main Building site. The building includes eight levels of clinic, diagnostic, treatment, and office space. The building design incorporates a unique village-like theme that encourages patient/staff interactions and will contribute to the institution's emphasis on patient comfort and healing. Architects and designers for the project were KMD of San Francisco, FKP of Houston, and O'Neill Hill and Associates, also of Houston.

Affinity Health System, Appleton, Wisconsin

Affinity (figure 4) is substantially expanding its clinic network to improve service to its patient population. The project mission is to create a clinic prototype of approximately 18,000 square feet, accommodating a six-physician practice that will become the standard for all future facility designs. The intention is to expand the network, adding a minimum of six to eight new clinics during the next five years. The goal is to create a truly community-based healthcare network that improves patient convenience, reduces travel time, and brings services to patients. The project architect is Flad & Associates in Madison, Wisconsin.

PeaceHealth Oregon Region, Eugene, Oregon

PeaceHealth (figure 5) is moving its main hospital, Sacred Heart Medical Center, to a property called RiverBend in Springfield, Oregon. The goals are to build a state-of-the- art medical center in a unique natural setting that provides a healing environment for patients, staff, and visitors; that supports patient/family-centered care; and is flexible, expandable, and adaptable. In addition, the principles of renewable and sustainable design, stewardship of the environment, responsible land-use and transportation planning, and the incorporation of public amenities and open spaces will guide development at RiverBend. The project architect is Anshen+Allen, based in San Francisco.

Banner Estrella Medical Center, Phoenix

Banner Estrella Medical Center (BEMC) recently opened a new hospital that provides a full scope of services, including open-heart surgery, with 165 private rooms and 450,000 square feet. The medical campus is situated on 50 acres of land in West Phoenix, one of the fastest growing regions in the nation. Six elements of the “hospital for the future” have been identified and were the design guidelines for BEMC: (1) flexible and adaptable, (2) effective information technology, (3) separate and connected inpatient and ambulatory space, (4) operational quality and efficiencies, (5) service excellence, and (6) a healing environment. NBBJ in Seattle was the project architect.

Columbia St. Mary's, Milwaukee

Columbia St. Mary's is early in the process of redesigning its care delivery processes and designing new facilities to replace/consolidate two urban hospitals and significantly expand a relatively new suburban hospital campus.

The guiding principles used for project direction and decision making include: (1) functional, flexible, and cost-effective facilities and operations; (2) control of the care experience by patient and family; (3) care provider environment that fosters a passion for patient care; (4) a unified culture representing the best of Columbia and St. Mary's; and (5) enhanced safety and improved outcomes in care delivery. Hellmuth, Obata + Kassabaum (HOK) of St. Louis is the lead architect.

Edward Hospital & Health Services, Naperville, Illinois

Edward Hospital & Health Services is planning a two-phase project on 60 acres of land to bring much needed healthcare services to Plainfield and the southwestern portion of the Edward Hospital service area. The first phase is to construct a three-story (with basement) medical office building and an outpatient center. This project is scheduled for completion by June 2006. The second phase involves construction of the new Edward Plainfield Hospital, a 146-bed, 299,929-sq.-ft. facility complete with ancillary services, a 20-bay ED, and six surgical suites. The hospital will include 96 medical/surgical beds, 30 obstetric beds, and 20 ICU beds. Its Pebble-related goals are still being determined. The project architect is Matthei & Colin Associates in Chicago.

St. Elizabeth Hospital, Appleton, Wisconsin

St. Elizabeth Hospital (figure 6) has undertaken implementation of a multiphase master plan for its Pebble Project. Phase I is designed to improve patient access and wayfinding. The project consists of a 438-stall parking structure and a 50,000-sq.-ft. addition that will house Patient Registration, Outpatient Test Center, Nuclear Diagnostics, Cardiopulmonary Department, Laboratory, Rehabilitation Gym, Internet Café, Resource Center, Gift Shop, and a beautiful two-and-a-half story atrium serving as the primary entrance. Emphasis on sustainability will be an integral part of all components of the design. HGA is the design firm.

Shawnee Mission Medical Center, Shawnee Mission, Kansas

The main feature of Shawnee's project is a 204,000-sq.-ft., five-story patient tower, increasing the overall hospital square footage by 40%. The new tower will house a 40-room ED, surgery department, 36-bed acuity-adaptable cardiac care unit, and 26-bed super-acuity ICU, and will track clinical and financial data generated by the structure. HMN Architects, Inc., and NBBJ are the design firms for the project.

St. Benedict's Family Medical Center, Jerome, Idaho

St. Benedict's, part of the Saint Alphonsus system, plans to build a 25-bed inpatient hospital on the site at a cost of between $16 million and $18 million. Future plans include the addition of a long-term care center, outpatient center, and medical office complex. Pebble-related goals are still being formulated, and the design team has not yet been selected.

Village Care of New York, New York

Village Care, which operates the only residential healthcare facility on the West Side of Manhattan, is building two replacement facilities to create five unique types of specialized settings in two buildings. The project includes a 60-bed setting dedicated to intensive, state-of-the-art rehabilitation services; a five-bed setting dedicated to the unique service needs of young adults with chronically debilitating neurologic diseases; a 15-bed “Green House” group setting, with resident rooms grouped around a common area, for older adults requiring long-term care; a 45-bed setting dedicated to person-centered dementia care; and three 15-bed “Green Houses” in an urban, vertical layout. Expected completion is January 2007. Perkins Eastman of New York City is the design firm.

Community Mercy Health Partners, Springfield, Ohio

Community Mercy is building an estimated $280 million, 300 to 350-bed replacement hospital. The result of the merger of two entities, the new hospital will merge two different cultures in one new facility. Community Mercy plans to compare the statistics of the two “before” hospitals with the “after” of the new combined facility. No design firm has been selected yet.

St. Joseph's Hospital, West Bend, Wisconsin

St. Joseph's has built an 80-bed, $55 million replacement hospital that began admitting patients in August 2005. It is the nation's first hospital specifically designed to deliver safe, error-free medical treatment. To meet those goals, a specific set of safety-focused design recommendations were developed, with specific areas of research including: sound attenuation and vibration studies, air quality effect in infections, the impact of lighting on patient diagnosis and assessment, flooring surface safety, bed exit safety, MRI-related injury, etc. The design firm for the project is Gresham, Smith and Partners.

OhioHealth, Columbus, Ohio

A 100-bed acute care hospital will be the newest addition to the OhioHealth system, a regional system of hospitals, home care services, and ambulatory sites. The project was scheduled for groundbreaking this summer, with an opening set for October 2007. Karlsberger of Columbus, Ohio, is serving as the lead architectural firm, partnering with smaller local firms and using the services of interior design firm CAMA, Inc., of New Haven, Connecticut, as a creative/healing environment consultant.

Provena Saint Joseph Medical Center, Joliet, Illinois

Provena Saint Joseph Medical Center is constructing an eight-story tower with a basement to accommodate 199 new patient rooms on the west side of its existing Medical Center. Expected completion is 2010. The patient rooms will house medical/surgical, pediatric, and ICU beds. The project also includes the demolition of the college of nursing, relocation and expansion of the existing boiler house, relocation and construction of the loading dock, and construction of an 864-space parking garage. The design firm is PFB Architects of Chicago, and Pebble-related goals are being determined.

Palomar Pomerado Health (PPH), Escondido, California

PPH is renovating two hospitals and building a new one, with the goal of opening the “best public hospital in America” in 2010. To achieve this, it has created four “Champion Teams” that are being led by a Center for Health design “coach” to explore issues of quality, customer service, financial strength, and workforce/workplace development. PPH also plans to measure a variety of operational and health-related outcomes over the next six years, creating a baseline for changes anticipated to occur as a result of the cultural transformation and new building designs emerging from the Champion Teams' work. The project architect is Anshen+Allen.

Laguna Honda Hospital and Rehabilitation Center, San Francisco

Laguna Honda is adding 1,200 acute, rehab, and skilled nursing facility beds to its 62-acre campus. It is also expanding adult day healthcare, Alzheimer's, and skilled nursing programs by 30% and adding outpatient clinics, dialysis service, 140 assisted living units, and a child- care center to its continuum of care. The $400 million project will be completed in phases between 2007 and 2011. Laguna Honda has data from its existing facility on employee turnover, outcomes, length of stay, cost per unit of service, and violence perpetrated on staff, which it plans to use as benchmarks for measuring the impact of its new facilities. The design team includes Anshen+Allen and Chong Partners Architecture, both based in San Francisco, and a team of 43 specialty consulting firms (e.g., structural, mechanical, landscaping, acoustic, etc.).

SSM Health Care–St. Louis, St. Louis

SSM Health Care-St. Louis (SSMHC-St. Louis) is building a new $215 million campus on a 54-acre site in Southwest St. Louis County that is planned to open in April 2008. The campus will include a hospital, an ambulatory care center, and a medical office building. SSMHC-St. Louis plans to use the goals of the Institute of Medicine (IOM) Committee on Quality of Health Care in America as the basis for designing a replacement hospital to deliver care that is safe, effective, patient-centered, timely, efficient, and equitable.

The chosen site currently operates as a nine-hole golf course covered with old-growth trees, with a 16-acre pond and gently rolling hills, all of which SSMHC-St. Louis believes can be adapted to provide a superior healing environment. No architecture or design firm has been selected.

Lake Hospital System, Lake County, Ohio

Lake Hospital System (LHS) is replacing its existing LakeEast Hospital acute care facility in Painesville, Ohio, with a new 125+-bed, 306,000-sq.-ft., full-service hospital and 55,000-sq.-ft. medical office building. Using evidence-based design, the goal is to create a healing environment that is family-focused and supports patient-centered care, safety, operational efficiency, and learning. All patient rooms will be private, and the environment will be designed for paper-light, wireless, and filmless record keeping. Functional and space programming for the new hospital is complete, and schematic design began in the first quarter of this year. Occupancy is scheduled for mid-2008. The project architect is Karlsberger, with interior designers CAMA, Inc.

St. Joseph's-Baptist Health Care, Tampa

St. Joseph's is building a new medical office building and regional 76-bed hospital to serve the northern/northwestern Hillsborough County population. The facility is being designed to meet the following operational and patient care goals: increase patient accessibility and comfort; enhance privacy and security; use materials, finishes, and systems that maximize operational efficiency; and create environments supporting St. Joseph's focus on the family. The medical office building is expected to open in 2006, and the hospital in 2008. The design firm for the project is Raôn & Partners, Inc., Architects, of Tampa.

Sara O. Marberry is President of Sara Marberry Communications, a marketing communications consulting firm in Evanston, Illinois. In addition, she serves as the consulting Director of Communications for The Center for Health Design, an organization with which she has been associated for more than 15 years.