Twice a year, The Center for Health Design’s (CHD) Pebble Project partners have the opportunity to meet at a host site, share ideas, provide updates on their projects, and learn from one another. In May, this meeting crossed the border for the first time and was hosted by the Vancouver Island Health Authority (VIHA) and its Royal Jubilee Hospital in Victoria, British Columbia.

It is appropriate that the first international meeting was held in Victoria, as VIHA was the first international organization to join the Pebble Project. The Patient Care Centre (PCC) at Royal Jubilee Hospital is a 500-bed, 420,000-square-foot tower that opened on March 13, 2011.

Opening reception

During the opening reception, attendees heard from leaders at two Pebble Partner organizations: Howard Waldner, president and CEO at VIHA; and Barry Rabner, president and CEO of the Princeton Healthcare System, which is building the new University Medical Center at Princeton (UMCP) in Plainsboro, New Jersey (UMCP is a 630,000-square-foot hospital with 231 single-bed patient rooms and is planned to serve as the hub of a 171-acre health campus with medical offices, nursing and rehabilitation services, and facilities for fitness, health education, assisted living and independent living). Both spoke about the development of their respective facilities from the owner’s perspective —the PCC as a public-private partnership and the UMCP as a private development for a non-profit organization.

The most conversation was generated when it was suggested that to truly impact outcomes and advance evidence-based design, the design team should have some “skin in the game,” with compensation and fees linked to intended performance. This drew some reaction from the architects and designers in the room, who expressed concern about being accountable for operational issues that could affect the intended performance of the building once in use. Sidebar discussions continued throughout the meeting on this topic, with varied ideas, such as the design team members contributing funding to EBD research, if not being specifically accountable for outcomes, as well as commitments from providers to “do what is planned” and properly prepare staff.


The Pebble Colloquium host

The onsite presentation was led by VIHA executive team members Waldner and Rudi van den Broek, chief project officer and general manager, special projects. In addition to touring the new facility, attendees learned the PCC is leading-edge in three key areas–the environment, staff, and patients. The founding principles of the project included a focus on:

  •        Quality and patient safety;
  •        An elder-friendly environment that enhances functional ability for all;
  •        Being patient-centered and visitor-focused;
  •        Providing an attractive and safe workplace;
  •        Providing capacity for seamless introduction of future technologies;
  •        Being environmentally friendly; and
  •        Demonstrating community responsibility.

Some of the project’s highlights include more than 80% single rooms with private bathrooms for enhanced privacy, confidentiality, comfort, and infection control (including 1,400 sinks); ceiling-mounted lifts in all patient rooms (with tracks to the bathroom); state-of-the-art design and technology in accordance with LEED Gold standards; and access to natural light, 100% natural ventilation, and green spaces for staff, patients, and visitors.

Earlier this year, as part of its Pebble participation, the PCC team invited several experts to evaluate their pre-occupancy design conditions. Evaluated on 106 components in 12 areas of focus, the PCC excelled in:

  •          Flexibility, adaptability, and modular design;
  •          RFID, communication technology;
  •          Code path light in unit corridors;
  •          Ceiling lifts;
  •          Bathroom design;
  •          Patient control features (bed, lighting, communication, privacy);
  •          “Bringing care to patient”;
  •          Access to views;
  •          Hand hygiene locations (sinks and alcohol gel dispensers);
  •          Negative pressure rooms; and
  •          Door hardware.

The project is a public-private partnership between VIHA and ISL Health. ISL Health is responsible for the design, building, financing, and maintenance of the facility within a 32.5-year contract (inclusive of the construction phase), while VIHA always retains ownership of the facility and provides all health and medical services. A recent recipient of the Best International Project award from the Public Private Finance Awards, it was recognized for outstanding achievement in a public-private partnership. The awards competition graded Royal Jubilee’s PCC project on seven elements, including effective risk assessment and transfer; quick financial close; design quality and sustainability; flexibility/alternative asset use; innovation; promotion of environmental measures; and operational per
formance. As a project that was just a concept in 2006, with a groundbreaking in mid-2008, the team also did an outstanding job of designing and occupying the building in such a constrained timeframe.


Meeting presentations

In addition to the first day’s onsite tour and presentation, Pebble Colloquium participants heard two invited guests—Michael G. Schmidt, PhD, director, Office of Special Programs, professor and vice chair, department of microbiology and immunology, Medical University of South Carolina; and Peter Sharpe, MBA, EDAC, of Irwin P. Sharpe & Associates, in New Jersey—speak about an ongoing study about the use of surface materials in the risk mitigation of hospital-acquired infections (HAIs) in the ICU.

Highlighting the importance of this topic, the presentation reinforced the sobering statistics that 4.5% of patients admitted to the hospital will acquire an HAI, and once infected, there is a 1 in 20 chance of death. This increases to one in four if you are a patient in the ICU.  HAIs are the fourth leading cause of death in the United States behind heart disease, cancer, and strokes. And, according to the CDC, HAIs add 208% to the hospital bill.

Additional data from the Pennsylvania Health Care Cost Containment Council (February 2011) revealed that in 2009, 1.9 million patients were treated in Pennsylvania hospitals, and the mortality rate with an HAI was 9.4%; for those without an HAI, it was only 1.8%. The average length of stay with an HAI was 21.6 days and without only 4.9 days.

There are additional implications related to readmissions and the Medicare cost consequences. The related business case conservatively estimated a return on investment of less than one year and accounted for the component costs of the design interventions, and costs associated with a reduced rate of infection, cleaning, and litigation.


Additional updates

Anjali Joseph, PhD, EDAC, CHD’s director of research, and Carolyn Quist, EDAC, a senior project manager at CHD, provided an update about the advances in the development of the RIPPLE database, including a new direction for Pebble research that links sustainable building design to healthcare outcomes. This was followed by a brainstorming session centered on Pebble research priorities, facilitated by Frank Weinberg and Frank Becker, PhD, the current co-chairs of CHD’s Research Coalition. Research focus areas and tools were discussed and will be used to inform the further development of the Pebble Project.

Additionally, research updates were provided by:

  •          Kathy Harper, RN, MBA, EDAC, and Gena English, RID, AAHID, EDAC, RAS, from the Parkland Health & Hospital System, Dallas, who spoke about the challenges of choosing a research project;
  •          Diana Halfer, MSN, RN, NEA-BC, from the Ann & Robert H. Lurie Children's Hospital of Chicago, who spoke about using virtual reality to prepare the workforce for a move;
  •          Susan Lorenz, RN, DrNP, NEA-BC, EDAC, from the Princeton Healthcare System, who discussed progress on the Model Patient Room study, whose latest phase in a live environment is being funded by the Robert Wood Johnson Foundation;
  •          Marie Fontaine, MAAA, MRAIC, LEED AP, EDAC (Alberta Infrastructure), Bev Knudtson, BID, EDAC (Alberta Health Services) and Lynne Webster, AAA, OAA, AIBC, FRAIC, LEED AP (DIALOG), who provided lessons learned and an update for the building performance evaluation (BPE) of the new patient unit at the Peter Lougheed Centre in Calgary, Alberta. (Some of the findings will be presented in a forthcoming Pebble Report); and
  •          Robert Breen, EDAC, of Provincial Health Services Authority, who spoke about use of Lean 3P in the building design of the Children’s and Women’s Health Centre Project in Vancouver, British Columbia. As described by Breen, Lean 3P is typically used by organizations that have experience implementing other Lean methods and is more comprehensive than a typical Lean process. It offers the potential to make "quantum leap" design improvements beyond those found through continual incremental improvement of existing processes. He further described 3P as “Lean on steroids.”

Lastly, Dan Miesle, EDAC, provided a preview of the University of Kentucky Albert B. Chandler Hospital project, which will be the host facility for the fall 2011 meeting.



For more information about the Royal Jubilee Hospital PCC, visit Ellen Taylor is a research associate/consultant with The Center for Health Design.