More and more design professionals and healthcare leaders are finding value in utilizing an evidence-based design process to build better buildings that help improve quality and safety. While the terms “evidence-based design” and “healing environments” have become mainstream, many healthcare leaders and design professionals are still just beginning to understand what they really mean.

Anecdotal evidence isn’t enough to convince decision makers to invest more in new healthcare facilities. If hospital CEOs are to embrace and implement evidence-based design, they will first want to evaluate potential costs, identify benchmark facilities, and see credible and relevant research. This is where The Center for Health Design’s (CHD) Pebble Project comes in. It plays an important role in contributing to the body of knowledge and evidence that exists in the field of healthcare design today.

In its early years The Center’s work mostly involved pulling together pre-existing data and information and finding funding for various research projects. The idea to engage healthcare providers to conduct and document research that affects outcomes emerged through the CHD Board of Directors, who gave the initiative its iconic name. The goal was to create a ripple effect in the healthcare community and contribute to what was then the relatively unknown science of evidence-based design. By committing to using an evidence-based design process and then documenting and sharing the results, Pebble Partners would help advance the field and promote change.

Apparently, it was an idea whose time had come. Launched in 2000, the Pebble Project has grown rapidly. There are now has more than 50 Pebble Partners (two of whom are international) at various stages of project development, providing ongoing researched and documented examples of how design has made a difference in the quality of care and financial performance of their institutions. In addition, several product manufacturers have joined as Corporate Pebble Partners to collaborate with providers to conduct specific research.

What does it mean to be a Pebble Partner?

This one of a kind, international research initiative comprises a diverse community of progressive healthcare organizations and professionals who have committed to applying an evidence-based design process to create healing environments that improve the quality of care, promote safety and health, and increase operational efficiency. These organizations may be different in many ways, yet they share some crucial commonalities: a willingness to push the envelope and not fall prey to the inhibitions of current thinking in healthcare delivery; to ask questions differently about the cultural shifts and technology needed to improve outcomes; and then to use design elements to support those behaviors. Pebble Partners also have progressive corporate cultures that seek to create optimal healing environments while proving to be economically sustainable.

The Center for Health Design views each Pebble Partner as a significant transformer and engages each on its own merit while providing the necessary guidance to successfully learn, apply, analyze, and document the effect its new facility design has created on its patient and staff outcomes in addition to its organizational behavior. One of the greatest benefits of being part of the Pebble Project is the guidance that Partners receive as they go through the process–research and programming expertise and resources that are hard to find elsewhere.

Twice a year, Pebble Partners convene for an exclusive three-day meeting to present cutting edge research and emerging ideas about evidence-based design, and information relevant to innovative building design and operations. The CHD staff, consisting of researchers, marketing professionals, and industry experts attend these meetings, along with members of the CHD Board of Directors—a distinguished group of healthcare thinkers and design leaders.

These “think tank” sessions allow for learning and sharing in a relaxed, yet focused format that promotes networking and community. Attendees at these meetings—like-minded healthcare executives, clinicians, design professionals, product manufacturers, and industry experts—report that learning from each other and being able to share unique perspectives and experiences is an invaluable part of the program. Nowhere else can Pebble Partners gain such access to world class expertise.

Pebble Partner organizations have an innate desire to gain an understanding of how to apply verifiable methodologies to plan, design, and construct new healthcare spaces. The Pebble Partners have a common goal—to provide evidence of the impact a new or improved building or space can have on a variety of outcomes. As a result, Pebble Partners conduct and publish pre- to post-

occupancy research in academic journals and industry trade magazines such as this one.

Pebble Partners take on at minimum one research project, although several choose to conduct multiple research projects. The range of topics varies among Partners. The topics covered in Pebble Partner research projects typically include clinical improvement, patient and family satisfaction, organizational change, and financial performance.

The opportunity to join the Pebble Project is open to any type of organization that provides or creates healthcare environments. Healthcare organizations have the opportunity to become a Pebble Partner at any stage within the life cycle of a facility, with a commitment to being a Partner for a minimum of three years. Typically, organizations that join the Pebble Project are early in the design and development of a new building or renovation project. In some cases, the architectural design firm has already been selected and the project team is in place. In other cases, Pebbles get assistance selecting an architect and design team with an understanding of evidence-based design.

Current membership includes representation from:

  • Large and small acute-care health systems

  • Academic, research, and teaching hospitals

  • For-profit national hospital chains

  • Ambulatory care facilities

  • Specialty hospitals

  • Senior living environments

  • Urban tertiary medical centers

  • Suburban hospitals

  • Government health authorities

  • Healthcare equipment providers

  • Architectural and design professionals

2008 promises to be exciting for the Pebble Project. The opening of several new facilities presents opportunities for some Pebble Partners to begin developing their research plans and for others to substantiate their preoccupancy research hypotheses.

ER One at Washington Hospital in Washington, DC, is examining the impact of different combinations of exam room finishes on pathogen levels and infection rates in the emergency department. Dublin Methodist Hospital, which just opened a state of the art facility in Dublin, Ohio, plans to track the cost of different EBD interventions and evaluate cost-benefit of those interventions throughout the facility. Froedert Hospital in Milwaukee is examining the impact of an integrated interdisciplinary care model of communication, satisfaction and efficiency. Jersey Shore University Medical Center in Neptune, New Jersey, is looking at the impact of unit renovations on sound quality and noise levels and is partnering with Armstrong Commercial Ceiling Systems, a Corporate Pebble Partner on this project. Children’s Hospital in Denver is working with Johns Mannville, another Pebble Partner. The Sacred Heart Medical Center in River Bend, Oregon, which is set to open in August of this year, has been studying the effects of ceiling lifts on staff injuries and claim costs. These research projects will help these facilities and others in making important design decisions while at the same time making significant contributions to the field of evidence based design.

When The Center started the Pebble Project, the goal was to create a ripple effect in the healthcare community. Eight years later, the ripple has turned into a wave, with the first 50 Pebble Partners riding the crest. And while not all 5,000 hospitals in the U.S. may become Pebble Partners, the goal is to use the work done by these pioneers to engage each and every one of them to build facilities that help to improve the quality of healthcare. HD


To learn more about The Pebble Project, visit The Center’s Web site at For more information about becoming a Pebble Partner, contact Mark Goodman at The Center for Health Design, 1850 Gateway Boulevard, Suite 1083, Concord, CA, 94520, or 925.521.9404, x120.

The Center for Health Design is a nonprofit research and advocacy organization of forward-thinking healthcare, elder care, design, and construction professionals and product manufacturers who are leading the quest to improve the quality of healthcare facilities and create new environments for healthy aging. To comment on this article, visit