Pebble Partners' commitment to utilize an evidence-based design process within their healthcare building projects is reinforced through the contribution and enthusiasm of their architecture and design teams. Having architecture firms involved, and in many cases, lead evidence-based design discussions, can maximize the outcomes associated with the implementation of the evidence-based design process. The following architecture firms, all who are involved currently with Pebble Projects, were asked what it means for their organization to be part of an interdisciplinary Pebble Project team: Zimmer Gunsul Frasca Architects LLP (ZGF); Anshen + Allen Architects; H + L Architecture; Hammel, Green, and Abrahamson, Inc. (HGA); OWP/P; and HOK.

What do you see as the difference between working with a Pebble Project Hospital versus a non-Pebble Project hospital?

Sue Ann Barton, AIA, LEED AP: While most of our healthcare clients are committed to providing a quality environment and incorporating the concepts of evidence-based design into their projects, those that choose to be Pebble Partners show commitment to the implementation of evidence-based design principles into the ongoing operations of their facilities, and an interest in testing the success of the design. They have an enthusiasm for being on the cutting edge and contributing to collecting the evidence base.

Bill Rostenberg, FAIA, FACHA: While in some cases non-Pebble Project hospitals may be just as interested in evidence-based design and best practice thinking as are their Pebble counterparts, the fact that they are Pebbles demonstrates a commitment to having a sound basis for justifying design decisions in order to improve operational and financial outcomes, improving safety, and reducing medical errors. As a Pebble, each hospital has become part of a shared-information network, which enriches the pursuit of design excellence.

Fred Buenning: The difference is a hospital's willingness to evaluate themselves and explore topics when they do not necessarily know what the outcome will be and back up their discoveries with evidence. It also establishes their commitment to invest in improving the body of evidence to base their design and medicine on.

Scott Lindvall, AIA: Pebble Project hospitals have made a commitment to studying and improving the care that they provide to their patients and families. We help by sharing our collective knowledge and working with those hospitals to create solutions that advance care delivery. As a team, we are able to measure the level of success those solutions attain.

Jocelyn M. Stroupe, IIDA, AAHID: The difference is the client's commitment to research-focused on outcomes impacted or influenced by the built environment. Although we typically will introduce the use of research into our project process for all projects, the difference primarily is the commitment the hospital has to research-using a more rigorous process and focus the research topic on the impact of the built environment. Non-Pebble Hospitals may employ research, but generally are not focused on topics focused on the built environment as much as operational outcomes or satisfaction.

Nicholas Watkins, PhD: By understanding the relationship between design and outcomes, the healthcare organization is exceeding institutional standards and seeking to be the standard other organizations emulate. From the design practitioner's vantage point, the feed-forward/feedback cycle afforded by the research and design process translates into further design innovation. Each Pebble Project builds upon and learns from the innovations and experiences of the previous one, therefore continuing to increase the ever-growing basis of knowledge and research. Consequently, designers and planners feel informed and inspired and are motivated to exceed and accelerate potential for further innovation.

What aspects of the Pebble community have you found to be useful in creating greater value for your other clients?

Barton: The Pebble conferences are relatively small and are good networking opportunities to find like-minded colleagues. The personal connections expand our resource base as we explore different design ideas and strategies. This exposure to other Pebble members and their studies gives us information that we can share with other clients as background to guide the integration of evidence-based design in other projects.

Rostenberg: The ongoing blogs create a transparent and efficient means of multimember correspondence. Also the involvement of the Global Health and Safety Network Initiate-especially the RIPPLE Database-provides easy access to some of the best practice thinking on a variety of key issues including both conceptual and detailed solutions to improving safety and other clinical outcomes. In addition, the General Articles/Research Papers resource that is available to Pebble Partners is a ready reference tool supplying access to already vetted research and summaries regarding innovation implementation and design.

Buenning: The format and organization of the Pebble Project community provides a venue to discuss research strategies and methods and to share successes and challenges with other Pebble members. It also enhances our ability to inform groups like Board of Directors, senior management, staff, and patients on how facility design can influence patient outcomes.

Lindvall: The research generated by previous Pebble Projects has been valuable, but we've been surprised by everyone in the Pebble community's openness and willingness to help. We've asked Pebble Project hospitals if we could have other clients contact them to discuss shared operational and environmental concerns, and the responses have always been resoundingly positive. We have also found the corporate members to be very open. Many of them share not only their research within healthcare, but also lessons learned within their respective industries.

Stroupe: We have been able to share best practices, interact with others who may be encountering similar challenges, and share information on research. The camaraderie generated by the Pebble community is unique; this is created, at least in part, through the common goals all the Pebbles hold. Also, the opportunity to participate in ongoing dialogue has allowed us the ability to share our insights in an effort to help others. We have found that when we have posed a question, that we have gained excellent insights that have assisted us in providing our clients with information on best practices.

Watkins: The Pebble community has provided various media through which to advance a growing corpus of empirical research (e.g., articles, presentations, collaborations, and peer review with experts normally not accessible under the auspices of one organization). In turn, The Pebble community has caught the attention of our more conservative clients who need encouragement to push the envelope or take a lead.

How has your intellectual and practical knowledge of evidence-based design been altered by your participation on a Pebble Project?

Barton: Being on a Pebble Project team heightens your awareness of the need to be able to quantify or test the impacts of your design decisions. This stimulates more focused thinking about how the design strategy being implemented is supporting the goal being sought. Practically speaking, the access to staff at The Center for Health Design has been extremely helpful in trying to define the goals and strategies for research.

Rostenberg: Our participation and leadership on multiple Pebble Projects has reinforced our commitment to and pioneering of novel ways to solve key issues facing our clients. It has broadened our sensitivity to the myriad issues (some are obvious and others are more subtle) that must be addressed at the outset of any new project. Participation in Pebble meetings has given us new insight into both the challenges and solutions that manifest in Pebble Projects across the country.

Buenning: Our knowledge has increased dramatically, especially in the patient- and family-care arenas, as has our knowledge of the challenges of scientifically measuring and substantiating the design parameters we espouse with evidence. Our studies focused on centralized versus decentralized caregiver stations; patient and staff satisfaction with light, noise, temperature and aesthetics; their perceptions of safety, security and privacy; and the use family respite areas and amenities. We have been challenged and are still pursuing ways to track work flow and staff efficiency, and to isolate and measure the private versus semiprivate patient room impact on nosocomial infection rates between the previous facility and the new replacement facility.

Lindvall: We've been incredibly fortunate to have demanding clients who have encouraged us to look, listen, and learn with them. The Pebble Project is a natural part of that, and our Pebble Project clients are working to review the outcomes of their projects. We wholeheartedly embrace this as the economy tightens and expectations of our healthcare system continue to rise, because that rigor helps us make informed decisions with our clients. Those decisions positively affect the care they deliver, as well as their bottom line.

Stroupe: We have conducted a variety of research projects in the past but typically none that were based on a scientific, rigorous process. By engaging the Pebble research team to guide us in the structure of our research project, we have been able to define our research process as well as the team of researchers needed for our work effort. The Pebble research team and the dialogue with other Pebble Partners has also been helpful in identifying sources of funding for our research efforts. The ability for us to share the information internally to our healthcare market has been extremely valuable to our ongoing dialogue related to evidence-based design and the infusion of research into other project's processes.

Watkins: One of the most rewarding aspects of our participation in the Pebble community is access to a growing body of peer-reviewed research we can refer and contribute to, which allows us to internally advance our design practice and share it with the larger field of healthcare design. For example, we have learned strategies for integrating research into design practice, as well as having the opportunity to learn from the research generated from other Pebble Projects.

What qualities does an architecture firm need to bring to the table to work on a Pebble Project?

Barton: The architecture firm should have a commitment to design, research, and innovation, and an agenda toward the real improvement of healthcare design. There needs to be a willingness to collaborate and share ideas and strategies with others with a goal of contributing to a world-wide knowledge base.

Rostenberg: A firm must have the ability to see solutions to old problems in new ways. One should be willing to experiment, collaborative, good listeners, able to dig deep in search of true evidence, and unwilling to accept trends as evidence just because others have implemented them.

Buenning: You should have the curiosity to test your beliefs and a willingness to participate pro bono above and beyond basic architectural services to serve a higher purpose of improving design, healthcare, and patient outcomes.

Lindvall: Architectural firms involved with a Pebble Project should be inquisitive and open. They have to really want to know what the critical issues are and how they can best be solved. Then we have to be open to the results of the research. Sometimes the results are the antithesis of the team's expectations, but that can be even more informative. The important thing is that the team, the care providers, and the designers learn from the information and use it to continue to improve healthcare and healthcare environments.

Stroupe: A commitment to research: utilizing evidence-based design in practice requires our healthcare professionals, from the most inexperienced junior to the most senior, to become informed experts in a variety of areas within the healthcare arena. An interdisciplinary/collaborative approach to problem solving: The complexity of healthcare projects and advancing research to its highest level requires a team of individuals who work together in a collaborative manner.

Watkins: We believe the firm should provide the means for design innovation, data collection, data analysis, research reports, and program development. Otherwise, the final design will be divorced from the research findings and the design process will not benefit from the streamlining offered by a collaborative research and design effort. HD


The Pebble Project creates a ripple effect in the healthcare community by providing researched and documented examples of healthcare facilities where design has made a difference in the quality of care and financial performance of the institution. Launched in 2000, the Pebble Project is a joint research effort between The Center for Health Design and selected healthcare providers that has grown from one provider to more than 45. For a complete prospectus and application, contact Mark Goodman at



Natalie Zensius and Amy B. Keller, M.ARCH, The Center for Health Design; Sue Ann Barton, AIA, LEED AP, Zimmer Gunsul Frasca Architects LLP; Bill Rostenberg, FAIA, FACHA, Anshen + Allen; Fred Buenning, H + L Architecture; Scott Lindvall, AIA, Hammel, Green, and Abrahamson, Inc; Jocelyn M. Stroupe, IIDA, AAHID, OWP/P; Nicholas Watkins, PhD, HOK


ZGF Pebble Projects:

  • Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois

  • The Children's Hospital, Denver, Colorado (Design Architect)

Anshen+Allen Pebble Projects:

  • Laguna Honda Hospital & Rehabilitation, San Francisco, California

  • Loma Linda University Medical Center, Loma Linda, California

  • Palomar Pomerado Health (PPH) Escondido, California

  • Sacred Heart Medical Center at RiverBend, Springfield, Oregon

  • Pembury Hospital, Turnbridge Wells, Kent, UK

H+L Pebble Project:

  • The Children's Hospital, Denver, Colorado (Architect-of-Record)

HGA Pebble Projects:

  • Affinity Health System-St. Elizabeth Hospital Addition/Renovation, Appleton, Wisconsin

  • SSM Health Care-St. Clare Hospital, Fenton, Missouri

  • Virtua Health, Inc.-Voorhees Replacement Facility, Voorhees, New Jersey

OWP/P Pebble Projects:

  • Froedtert and The Medical College of Wisconsin Clinical Cancer Center, Wisconsin

HOK Pebble Project:

  • University Medical Center at Princeton, New Jersey

Healthcare Design 2009 March;9(3):22-28