The University of Texas M.D. Anderson Cancer Center Ambulatory Clinical Building (ACB) is a new, 781,000-square-foot outpatient facility housing Gynecology, Genitourinary, and Breast Centers. It has been designed as a freestanding satellite to the remainder of the campus. Support functions also housed in the building and providing downstream activities for the patient population in one easy-to-access setting include Diagnostic Imaging, Radiation Oncology, and Diagnostic and Ambulatory Treatment Centers. The project was complex because the ACB was a design-build project in which design ran concurrent with construction; the project began in fall 2000, and occupancy began in March 2005.

Background and Methodology

A growing body of scientific literature demonstrates that a range of design characteristics can reduce stress, errors, and pain while simultaneously increasing referrals and staff retention—all thought to lead to better long-term outcomes for patients. 1,2 These characteristics include:

  • Noise levels

  • Pleasant distractions

  • Safety features

  • Wayfinding systems

  • Support spaces

  • Patient and family member/caregiver control

The ACB was designed and built to make the patient's experience as pleasant as possible. Consequently, patients receive their treatment in a state-of-the-art facility, and they are also treated in an environment of respite and rejuvenation that offers spacious lounge areas, garden plazas, and large windows that let in ample amounts of light. These elements should also serve to improve the experience of visitors and staff.

The purpose of M.D. Anderson's Pebble Project study is to determine whether the physical environment of the new ACB, compared to those of existing facilities, exerts a more positive influence on four populations:

  • Patient Contact Staff (patient service coordinators, clinic nurses, research nurses, advance practice nurses, nutritionists, social workers, case managers, patient advocates, chaplaincy, etc.)

  • Physicians (faculty, residents, fellows)

  • Patients

  • Family/Caregivers

Four Multidisciplinary Care Centers (MCCs) are included in the present study: three MCCs that moved into the ACB (Breast, Gynecologic [Gyn], and Genitourinary [GU]), and one MCC that remained in the same environment (Gastrointestinal [GI]).

For the Pebble Project, we measured how members of the four populations from the four MCCs perceived their environment before and after the move to the new building. The three time periods are 3 months prior to moving into the ACB (Time 1), 3 months after moving into the ACB (Time 2), and 12 months after moving into the ACB (Time 3). Patients completed the most surveys during Time 1 and 2 (414 and 621, respectively), followed by family members (291 and 286, respectively), staff (127 and 102, respectively), and physicians (51 and 56, respectively). Specifically, the survey included questions regarding perceptions of six design characteristics—noise levels, pleasant distractions, safety features, wayfinding systems, support spaces, and patient and family/caregiver control—referred to as built-environment factors (BEFs).

Photo by Craig Dugan ©Hedrich Blessing

The survey also asked questions regarding:

  • Willingness to recommend

  • Service quality

  • Communications culture

  • Supervisor support

  • Staff/physician competence

  • Commitment to institution

  • Safety culture

  • Time spent with patients

  • Job satisfaction

  • Job control

  • Teamwork

  • Fatigue

  • Emotional distress

  • Staff retention

These are referred to as behavioral factors (BFs) and provide an indication of how respondents perceive the organization and their own behavior (for example, whether they perceive “a lot of teamwork is going on at the facility”). The main goal of the study is to determine whether there was a change in the respondents' perceptions of the organization and their own behavior when they moved from the old facility to the new facility. The hypothesis is that the change in perceived outcomes will be related to a change in the perceptions of the built environment. The comparisons are being made for the four populations across the four multidisciplinary care centers.

Other objectives of this study are:

  • to assess how changes in perceptions of the BEFs between the old and new facility may be related to changes in operational results (e.g., Exam Room Utilization, Exam Room Turns, and Physician Productivity);

  • to assess how changes in perceptions of the BEFs between the old and new facility may be related to significant changes in patient outcomes; and

  • to determine if the measured perceptions of the ACB change significantly over time.

To meet these objectives, data will be collected, analyzed, and interpreted over the three aforementioned time periods from the four populations in the four MCCs.

Preliminary Analysis and Results

Because the study is ongoing and data still needs to be collected for the third time period, the analysis and results are preliminary in nature.

After the three MCCs moved, perceptions of the BEFs for the different populations were examined. The respondents perceived the new environment of the ACB to be more positive than that of the existing facility. Specifically, all groups of respondents (except the staff in one of the MCCs) had positive responses regarding noise levels, pleasant distractions, control, and support spaces after the move. Also, the environment was perceived as being safer by all groups of respondents in the three MCCs that moved. Furthermore, wayfinding was perceived by family members and patients as being more effective in the new facility. Perceptions of the BEFs by the different populations in GI—the MCC that did not move—stayed relatively the same. We are encouraged by the positive perceptions of the BEFs and believe that our third wave of data will provide additional insight about such perceptions.

Future Work

The surveys used in the present study measured perceptions of the six BEFs at a broad, general level. That is, within the six BEFs, there are several ways that each BEF is manifested. For example, “pleasant distractions” is a broad general category that manifests itself in the ACB as artwork, waterfalls, outside patios, flora, and aquariums. In the surveys, one of the broad general questions for pleasant distractions is “Our clinical work areas have features which are pleasant to look at.”

A second study will focus on the BEFs that show significant differences across populations and MCCs during the present study. For example, should one of those BEFs be pleasant distractions, the questions on the survey for the second study would be directed specifically at artwork, waterfalls, outside patios, flora, and aquariums. In addition to informing the scientific community about our findings, the results also have a practical application: They will be used to inform decisions about the remodeling of existing facilities and the design and construction of new facilities.

Photo by Craig Dugan ©Hedrich Blessing


Janet Turner Parish, PhD, and Leonard L. Berry, PhD, both of the Mays Business School, Texas A&M University, College Station, are integral members of the M.D. Anderson Cancer Center Pebble Project research team. They made significant contributions in planning and developing the survey instruments.

William Daigneau, vice-president of Operations and Facilities; Richard Murray, director of Performance Improvement; and Pamela Redden, project director, all of M.D. Anderson Cancer Center, also contributed to this study. HD

Jason Etchegaray, PhD, is Senior Improvement Advisor and Wayne Fischer, PhD, is Manager—Research for the Institute for Healthcare Excellence at The University of Texas M.D. Anderson Cancer Center in Houston. Janet Sisolak is Project Director and Susan Lipka is Executive Director of Capital Planning & Management at M.D. Anderson Cancer Center.

For more on the M.D. Anderson Cancer Center Ambulatory Clinical Building, see the April 2006 issue of HEALTHCARE DESIGN, pp. 64-69. To send comments to the authors and editors, e-mail


  1. Rubin HR, Owens AJ, Golden G. Status report (1998): An investigation to determine whether the built environment affects patients' medical outcomes. Pleasant Hill Calif:The Center for Health Design, Inc., 1998.
  2. Ulrich RS, Quan X, Zimring C, et al. The role of the physical environment of the hospital of the 21st century: A once-in-a-lifetime opportunity. Report funded by the Robert Wood Johnson Foundation for The Center for Health Design, 2004.


The Pebble Report focuses on the research efforts and interests of The Center for Health Design's Pebble Project partners, a project that began in 2000 with one provider and has grown to more than 30.

Healthcare Design 2006 May;6(3):8-10