In a year of political and economic change, The Center for Health Design's Pebble Project has shown consistent progressive growth. The program gained nine new Pebble Partners, bringing the total to 50 active national and international Partners and 12 alumni. Pebble Partners produced numerous credible research studies, saw rising rates in construction and occupancy, and there was ongoing interest from several stakeholders to learn about Pebble studies through publications and Webinars.

New Pebbles and overall representation

The nine new Pebble Partners expand the Pebble reach internationally into Canada and the United Kingdom (figure 1). The range of representation also continues to grow with large and small facilities and urban and community facilities—all focused on delivering cutting-edge designs and superior care that make a tangible difference on healthcare outcomes.

Pebble map

The status of pebble projects

New healthcare buildings, additions, and renovations can take years to complete as they move from inception and visioning through to design, construction, and occupancy. The implication is that related research studies also take years to develop, conduct, analyze, and publish. The good news is that nearly 40% of current and alumni Pebbles are now occupying their facilities, with close to 40% under construction. Almost a third of the related research studies are completed, with nearly 20% of the studies underway (figure 2).

Design and Research Status of Pebble projects

Pebble Colloquiums

As building projects are completed, some Pebbles have an opportunity to host one of two annual Pebble Partner Meetings, the Pebble Colloquiums. In 2008, these meetings were hosted by PeaceHealth (Sacred Heart at RiverBend) in Eugene, Oregon, and Saint Alphonsus Regional Medical Center in Boise, Idaho.

Attendees had the opportunity to hear presentations from their peers ranging from yet-to-be published cutting-edge research to industry-wide issues such as project financing in today's challenging economic environment. Participants also had access to the host's recently completed facility, with tours and breakout sessions related to specific topics of the design. Topics included evidence-based design in master planning, NICU, ICU, and med/surg environments; process redesign and staff engagement; the use of gardens and nature; philanthropy; and the integration of design into outpatient settings. Prior to construction, preliminary research was conducted at both of these facilities. The research allowed the design team to effectively evaluate design options being considered prior to the investment of the full construction project.


Ceiling lifts were installed in patient rooms within two units at PeaceHealth Sacred Heart Medical Center as a way to reduce the incidence and severity of work-related injuries related to slips, trips, and falls (figure 3). Over a five-year period, the team at Sacred Heart Medical Center tracked the number of injuries associated with patient handling and the cost of claims. The team found that the use of ceiling lifts has virtually eliminated staff injuries from patient handling (Joseph & Fritz, 2006). Additionally, the cost benefit of installing these ceiling lifts was significant. The annual cost of patient-handling injuries in these two units is 83% lower than before the installation of the ceiling lifts. Because of the success of this pilot study, the organization installed ceiling lifts in the majority of patient rooms. When the savings are applied house-wide, PeaceHealth estimates it will show a return on investment (ROI) in approximately 2.5 years in its new facility.

Patient lifts installed at PeaceHealth, Sacred Heart Medical Center at River Bend, Eugene, Oregon

Saint Alphonsus

While awaiting construction of the addition and renovation to the Medical Center in Boise, Idaho, Saint Alphonsus renovated a nursing unit in 2003 to test the research methodology it then used on the larger project (figure 4; Dubbs, 2004). Noise levels were reduced by designing larger private rooms, adding carpet to hallways, putting acoustical tiles on walls and ceilings, and relocating machinery and nurse charting away from patients. In the study, the average decibel level per patient room was less than 51.7dBA, the quality of sleep improved from 4.9 to 7.3 (on a scale of 0 to 10), and patient satisfaction scores improved during a three month comparison period.

The ICU at St. Alphonsus, Boise, Idaho

Additional areas of research

The research conducted by Pebble Partners is broadly categorized into several areas: overall healthcare quality, staff effectiveness, patient safety, environmental safety, and economic outcomes (figure 5). A summary of Pebble Project areas of study indicates that the current research is primarily focused on overall healthcare quality such as noise, lighting, satisfaction, perceived anxiety, art (19 studies), and staff effectiveness (14 studies). Other areas of study include seven studies on patient safety, five studies on environmental safety, four studies on the evidence-based design process documentation, three studies on economic outcomes, and two studies on workplace safety. These studies are all in various phases ranging from research process and design through to completion. To illustrate these phases of research, three projects are summarized below:

Pebble Research Categories

Weill Cornell Medical Center.

The Weill Cornell Medical Center was one Pebble that conducted studies related to the overall quality of healthcare. Conducted after the Weill Greenberg Center opened in 2007, the second phase of their study examined the perceived quality of care in an ambulatory practice setting. Key findings in a report published in the Health Environments Research & Design Journal (HERD) included:

  • The perceived quality of care at the new facility was significantly higher than in the old facility
  • Patients rated their overall visit significantly better than the old facility—this included an increased willingness to recommend the office, as well as decreased anxiety
  • Patients rated their perceived interactions with staff more favorably (more friendly, courteous, polite, caring, and reassuring)
  • Staff interactions with one another were improved

The study results were consistent with several past studies, each with different research designs and methodologies, suggesting the relationship between attractiveness of an outpatient facility and perceived quality of care is robust.

Many of the Pebble studies underway fit into multiple categories. For example, the studies underway at Dublin Methodist and Laguna Honda relate to overall healthcare quality, staff effectiveness, environmental safety, and economic outcomes.

Dublin Methodist. Opened in January 2008, Dublin Methodist incorporated many evidence-based design features: accessible roof gardens, acoustic interventions, acuity-adaptable rooms, artwork, bathrooms on headwalls with a handrail, decentralized/shared caregiver workstations, internal courtyards, large doors in patient rooms/bathrooms, large private rooms with family space, large windows, varied artificial lighting, like-handed rooms, operable windows in patient rooms, a water feature in the lobby, and well-located and highly visible hand hygiene stations. Studies underway will evaluate cost-effectiveness, patient safety, stress reduction and satisfaction, operational efficiency, and overall healthcare quality.

Laguna Honda. When Laguna Honda first began the process of determining study topics, they involved an interdisciplinary design team including staff representatives, the architecture firm of their building project, representatives from The Center for Health Design, and external design researchers to narrow down research topics. While many topics surfaced during the brainstorming sessions, three emerged as areas for further study. These include:

  • The impact of pharmacy automation and medication pass system to evaluate staff efficiency and patient safety
  • A study to determine the quantity and quality of residents' activities and engagement in the new campus and evaluation of satisfaction levels with related environments
  • The business case to determine whether the investment in evidence-based design and sustainable features can provide return on investment

Publicized Pebbles

Nearly 45 articles and Webinars featuring Pebble Projects appeared in magazines and journals throughout the year (figure 6). The topics range from general design such as creating the ultimate healing environment at Dublin Methodist to specific peer-reviewed research results such as open-bay and single-family room Neonatal Intensive Care Units at Memorial Indiana. Links to many of these articles are available on The Center for Health Design's Web site.

2008 Pebble Projects Dissemination

Moving ahead in 2009

The combined research and dissemination initiatives of the Pebble Project continue to advance evidence available to guide informed decision making in healthcare environments. Five more Pebbles are scheduled to occupy their facilities in 2009. These Pebbles plan to study noise levels, the impact of decentralized nursing, patient falls, and the impact of OR design on efficiency.

The next Pebble Colloquium will be held in Milwaukee, hosted by the Froedtert & the Medical College of Wisconsin. The Clinical Cancer Center at Froedtert offers evidence-based design features such as large windows, views to nature, semiprivate infusion areas, and accommodations for family and friends. The design supports communication and interdisciplinary learning—space for staff and patients to meet, flexible clinical module, and education spaces will be measured for both staff and patient satisfaction. The completed project was recently featured in the Wall Street Journal.

Additionally in 2009, Pebble Project data will be included in the Global Health Safety Initiatives RIPPLE database. The Global Health and Safety Initiative (GHSI) is a sector-wide collaboration to transform the way healthcare environments are designed, built, and operated, as well as considering the products used within those facilities. The GHSI was launched in October 2007 and the RIPPLE database is currently in beta testing.

The Pebbles will also be used as participants in an upcoming study for the Agency for Healthcare Research and Quality (AHRQ). The study, Safety and Quality in Healthcare: A Framework for Evaluating Evidence-Based Design, will be conducted for the AHRQ by Battelle, The Center for Health Design and the MANILA Consulting Group. While not a comprehensive list of the activities taking place in 2008, this report provides a snapshot of the Project now in its eighth year. The Center's hope is that the program continues to create a positive impact in healthcare design. HD

Ellen M. Taylor, AIA, MBA, is a Research Consultant at The Center for Health Design.

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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


Pebble Partners that joined in 2008 include:

Children's Memorial Medical Center (Illinois)

Health Care Project Ltd. (United Kingdom)

Loma Linda University Medical Center (California)

Maidstone and Tunbridge Wells (United Kingdom)

Queen of the Valley Medical Center (California)

Southlake Regional Health Centre and Stevenson Memorial Hospital and Medical Centre (Ontario, Canada)

Susquehanna Health Williamsport Hospital and Medical Center (Pennsylvania)

University Hospitals Rainbow Babies and Children's Hospital (Ohio)

Healthcare Design 2009 January;9(1):20-26