It is hard to believe, but this year marks the 10th anniversary of The Center for Health Design’s (CHD) Pebble Project. Launched in 2000 as a research collaboration between CHD and a few like-minded healthcare providers, the idea for the Pebble Project came during a joint meeting of CHD’s Board of Directors and Research Council in 1999. The minutes from that meeting state that board members Derek Parker, Blair Sadler, Roger Ulrich, and Bob Horsburgh described the project in detail, explaining that the idea was to engage “other organizations on research projects of common interest. The highest priority objective in this multi-organizational approach is to better understand how the planning and design process affects behavioral and cultural change in healthcare organizations that are striving to create a healing environment. A specific project-the organizational behavior or ‘pebble’ project-has been identified to address this objective.” The name was chosen because the idea was to create a ripple effect in the industry-just like a pebble does when it is tossed into a pond.

At that meeting, Sadler, who was then the CEO of Children’s Hospital in San Diego (now Rady Children’s Hospital), committed his hospital to be the first pebble. They were replacing a 30-year-old freestanding convalescent children’s hospital with a brand new facility that was being designed by the architecture firm, Anshen + Allen. The patient population and staff would be moving from an old building into a new one which offered the perfect opportunity to study the environment’s impact on outcomes.

Construction on the convalescent hospital was delayed due to financial constraints. During that time, the number of children in this patient population who could be cared for at home increased, and the number needing hospitalization decreased by a third. So, unfortunately the new facility was never built. But it helped to lay the groundwork and formally launch the Pebble Project.

The first organized meeting of the Pebble Project partners was held in San Francisco in August 2001 with about 20 individuals in attendance. By that time, the Barbara Ann Karmanos Cancer Institute in Detroit, Bronson Methodist Hospital in Kalamazoo, Michigan, and Clarian’s Methodist Hospital in Indianapolis had joined the project. At that time, the first research matrix had been developed to categorize the effects of the built environment into three types of outcomes: clinical/observable, economic, and patient/family/staff.

Since then, the research matrix has been refined and expanded, and Pebble has matured into a robust melting pot of multidisciplinary stakeholders representing the interest of healthcare providers, patients, and families. In the last 10 years, more than 70 organizations have become Pebble Partners and today the program has representation across the United States, Canada, and the United Kingdom. More than 110 individuals attended the last Pebble meeting, which was held in Philadelphia, Pennsylvania, in April. It has become custom during these bi-annual meetings to tour recently opened Pebble Partner facilities, and Mainline Healthcare’s new Paoli Hospital was the featured project at the April meeting. Pebble Partners learn firsthand from a provider organization’s management team about the importance of its involvement in the Pebble Project and its influence on the success of the project and the organization.

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

Facility Lifecycle Management and Performance Model
Facility Lifecycle Management and Performance Model

Now entering its second decade, the opportunity to join the Pebble Project is open to any type of organization that is involved in designing, building, or furnishing/equipping new or renovated healthcare facilities. Membership includes representation from: large and small acute care health systems, research and teaching hospitals, ambulatory care facilities, specialty hospitals, senior living environments, urban tertiary medical centers, suburban hospitals, government health authorities, healthcare equipment providers, and architectural and design professionals.

Organizations that choose to join the Pebble Project have an innate desire to gain an understanding of how to apply verifiable methodologies to plan, design, and construct new healthcare environments. All must want to prove and document the impact of what a new or improved space has on a variety of outcomes. As a result, those who join Pebble conduct and publish a variety of evidence-based design (EBD) research. Pebble Partners have progressive cultures, a desire to be transparent with their research findings, and are seeking to create optimal healing environments that promote safety, improve the quality of healthcare, and reduce the costs of operations.

In addition, it takes visionary leadership to successfully engage in the Pebble Project. Chief Executive Officers who understand and believe in evidence-based design are able to motivate and inspire their teams to realize the benefits of participating in the program. Those who attend the Pebble meetings develop a unique perspective on what it takes to build or renovate a facility that has an impact on patient, staff, and operational outcomes. In many cases, they become the EBD “champions” within their organizations.

Healthcare organizations may become Pebble Partners at any stage within the “Facility Life Cycle Management and Performance Model” (figure). Those who join commit to being a partner for a minimum of three years. Many organizations conduct multiple research projects, sometimes staying in Pebble long beyond their initial project and spanning into the next phase of development.

What’s most notable about the Pebble Project is that over a span of 10 years the lessons learned and the research conducted from this extraordinary group of professionals has dramatically influenced the design and outcomes of thousands of healthcare facilities around the world. Concepts such as single patient rooms, distributed or decentralized nurses’ stations, acuity-adaptable patient rooms, sound-absorbing surfaces, and visible handwashing locations have been tested and validated by Pebble Project research. In addition, the business case for building a better building-the Fable Hospital story (Berry L, Parker D, Coile R, Hamilton DK, O’Neil D, & Sadler B [2004]. The business case for better buildings. Frontiers in Health Service Management, 21[1],3-21)-would not have been possible without solid Pebble Project data.

Looking forward, CHD anticipates that the next decade of the Pebble Project will continue to stimulate creative new designs, build the scientific practice of evidence-based design, produce rigorous research results, and provide clear examples of how the design of the built environment can directly affect patient, staff, and environmental safety and the quality of care delivered. HD

Mark Goodman is Vice President of Project Development and Sara Marberry is Executive Vice President, COO, of The Center for Health Design.

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Figure source

  1. Malone EB Mann-Dooks JR Strauss J. Evidence-based design: Application in the MHS. (2007). Falls Church, VA Noblis.

Healthcare Design 2010 June;10(6):26-28