The prototype Pebble Project was created as a partnership between Children's Hospital and Health Center San Diego, Anshen + Allen Architects and The Center for Health Design. For the past decade, Children's Hospital has been committed to measuring and understanding all aspects of care, including the impact of architecture and design on the healing process.

The current Children's Convalescent Hospital on the campus of Children's Hospital and Health Center San Diego has been in existence for more than 30 years. A licensed 59-bed, long-term, skilled nursing facility, it is dedicated to the care of medically fragile children with complex chronic conditions. It serves as home to the children who reside there, giving them opportunities to attend school, participate in activities and receive specialized services.

Because itwas origin ally designed to serve adult convalescent hospital patients, the existing facility presents many functional problems. Therefore, the decision wasmade to build a new $25 million facility that will open in 2003. Driven by evidence-based design, the building project has parallel research and design teams. Anshen + Allen Architects, in San Francisco, is the project architect.

This Pebble Project has two unique components. The first is the emphasis on understanding how organizational behavior changes as a result of the planning and design process. The second is the development of a standardized evaluation methodology that, in turn, leads to comparison of outcomes and to identification of best practices and continuous improvements of healthcare design.

In preparation for the design, construction and postoccupancy evaluation of the new Children's Convalescent Hospital, we conducted focus groups and developed measurement instruments to quantify and characterize the built environment of the existing facility. The measurement instruments were designed in close collaboration with the stakeholders involved with the existing and planned facility (namely, parents, staff and senior management), and then integrated into a measurement model. The objectives of this work were to:

  1. develop a family of tailored measurement instruments in close collaboration with the stakeholders of the existing and planned facility;

  2. measure patient (when possible), parent and staff satisfaction with the built environment of the existing facility;

  3. assess parent satisfaction with the healthcare provided to the child; and

  4. assess staff satisfaction with their relationships with coworkers.

The measurement instruments developed to meet these objectives provide the template for other Pebble Project studies. Additional instruments are being developed to measure staff fatigue and the impact of having a medically fragile child with a serious, chronic health condition.

To help us meet the above objectives, we conducted a mail survey to assess:

  1. parent satisfaction with:

    • space provided for children's baths/showers

    • heating/air conditioning system

    • family rooms

    • privacy family has with child

    • amount of natural lighting

  2. staff satisfaction with:

    • size of residents' closets, activity rooms, dining room and staff break room

    • pictures in the hallway

    • facility lighting

    • windows

    • colors of walls

  3. parent satisfaction with:

    • the overall care child is receiving

    • how friendly and helpful the staff is

    • the effort made to include the family in discussions about the child's care

  4. staff satisfaction with:

    • their relationship with coworkers

    • support received from coworkers

Based on the findings from the focus groups and mailed surveys, the planned Children's Convalescent Hospital has undergone a number of significant design changes. For instance, patient room size and layout-including the size and positioning of the closets, wheelchair storage inside the bedroom closets, the amount of natural lighting and the bathroom facility accommodations-have been redesigned. Other changes include creating a more homelike family environment, such as a family visiting area that looks more like a family's front room.

The initial findings demonstrate that it is possible to quantify and characterize the qualitative aspects of the built environment using standardized instrument development methodologies. Leaders at The Center for Health Design and Children's Hospital and Health Center believe that, given the rising demands on healthcare resources and the need to allocate these scarce resources in the most cost-effective manner, it is vital to empirically document the impact of the built environment on patient health and well-being. These analyses illustrate the potential of using scientific methods in the empirical evaluation of the built environment of healthcare.

Children's Hospital and Health Center knows that parents and staff are key stakeholders and criticallyimportantinformants in the design of pediatric healthcare facilities. Their perceived needs for and satisfaction with the built environment can be rigorously, reliably and validly assessed. The development of standardized measurement instruments allows for the comparison of different facilities' ability to meet the needs of their key stakeholders.

As The Center for Health Design's Pebble Project hopes to demonstrate and encourage, the ability to compare results from before a facility was renovated with results from after the renovation-as well as comparing results from newly constructed facilities with standardized measurement instruments-leads to the ability to discover and share the best demonstrated practices in the design of healthcare facilities. The use of best demonstrated practices can lead to the continuous improvement of healthcare design, resulting in evidence-based design. The planned Children's Convalescent Hospital is anticipated to be a better facility and a more healing environment for children than originally designed, because of the quantitative input of its key stakeholders. HCD

James W. Varni, PhD, is senior scientist at the Center for Child Health Outcomes at Children's Hospital and Health Center San Diego ( Sara O. Marberry is the director of communications for The Center for Health Design (

http://www. and president of Sara Marberry Communications, Evanston, Illinois.


Pebble Project Partners

As of June 1,2001

The Barbara Ann Karmanos Cancer Institute, Detroit, MI

Bronson Methodist Hospital, Kalamazoo, MI

Children's Hospital and Health Center San Diego

Clarian Health Partners/Indianapolis Methodist Hospital, Indianapolis, IN


Healing Environments

There is some evidence that a “healing environment” might influence patient and family perceptions of their healthcare providers, as measured by healthcare satisfaction, quality assessments, intentions to return and willingness to recommend a healthcare provider to others. The commitment to a healing environment at Children's Hospital and Health Center San Diego began with the idea of a garden envisioned by the Hospital's Bereavement Committee in the late 1980s.

In 1993, with the creation of a Healing Environment Steering Committee, the focus of the garden shifted and it became part of an overall healing environment program at Children's Hospital and Health Center San Diego. The definition of the healing environment that guided these efforts is as follows:

“The Healing Environment is a term used to describe the physical and cultural atmosphere created to support families through hospital-ization, medical visits, healing and bereavement. Guiding the Healing Environment is a philosophy of caring; that is, the desire to develop a space that engenders uplifting feelings of peace, hope, joy, reflection and solace, and one that provides opportunities for relaxation, enrichment, spiritual connection, humor and play.

“Motivating this philosophy is the belief, which is supported by research, that these factors play a considerable role in the physical, emotional and spiritual healing process. The goal of the Healing Environment is to transform the hospital setting into a place that addresses the human spirit and supports families to positively cope with and transcend illness.

“The cornerstones of the Healing Environment are building design, the arts, family support and staff attitudes. Physical components of the Healing Environment are the interior and exterior building designs, gardens, family spaces and the art collection. Programmatic components of the Healing Environment are the arts and culture programs-musical performances, storytelling, artists-in-residence and the like.

“Equally important to the Healing Environment are the ways in which we support and treat our families-customer service, family-centered care and the Golden Rule of compassion and consideration.”