The goal of the Pebble Project, a research initiative launched by The Center for Health Design (CHD) in 2000, is to create a ripple effect in the healthcare community by providing documented examples of healthcare facilities that have used an evidence-based design (EBD) process to document outcomes.

Twelve years in, it’s interesting to note how the Pebble Project has evolved and may be an option to support your own EBD initiatives, whether it’s a new facility or a renovated space.

Since the inception of the Pebble Project, EBD has become an integral part of the healthcare design vocabulary—nearly three-quarters of respondents to a 2010 survey indicate using EBD (Taylor, 2011). In addition, CHD’s evidence-based design accreditation and certification (EDAC) program was launched to establish a structured framework around the process of EBD, while providing certification surrounding core competency understanding.

The Health Environments Research and Design (HERD) Journal was founded to provide a venue for peer-reviewed dissemination of healthcare-related built environment theory and studies, and many large architectural firms engage their own PhD researchers to conduct research and support and guide teams through the wealth of knowledge being generated throughout the industry.

When the Pebble Project was introduced, it was more of an open and undefined landscape; it was up to a few forward-thinking organizations to establish how they might better understand the implications of the built environment on healthcare outcomes.

The early work of the Pebble Project led to important discussions surrounding medication errors (Barbara Ann Karmanos Cancer Institute, Methodist Hospital-Clarian Health Partners); acuity-adaptable rooms (Methodist Hospital-Clarian Health Partners); and single-bed patient rooms (Bronson Methodist Hospital).

Many of these projects considered the financial implications of the outcomes, resulting in the 1994 Frontiers article about the Fable Hospital. This “hypothetical” facility was based upon many of the outcomes that had been documented by the early Pebble projects (Berry et al., 2004).

More recently, discussions have focused on the aesthetics of space and its impact on the waiting experience and quality of care (Weill Cornell Physician Organization – Weill Greenberg Center); acoustics in healthcare environments (Affinity Health, Jersey Shore University Medical Center, Palomar Pomerado Health); safety issues, such as the use of ceiling-mounted lifts in patient rooms (PeaceHealth); green cleaning (Healthy Hospitals Initiative); and taking the use of mock-ups to a new level with a live room in an existing facility (University Medical Center of Princeton at Plainsboro).

In the past few months, several Pebble Partners have opened their projects, including Susquehanna Health’s Williamsport Hospital and Medical Center, the University Medical Center of Princeton at Plainsboro, and the new Ann & Robert H. Lurie Children’s Hospital of Chicago. More Pebble Projects are scheduled to open later this year.

So how has the prevalence of EBD changed the Pebble Project?

Just as the industry has become more sophisticated with new project delivery processes and considerations of adaptability and flexibility in design solutions, CHD has been working to create additional support structures and flexibility within the Pebble Project. These have been in response to the growing use of EBD as a process and the expanding body of EDAC-certified individuals and organizations interested in more effectively using an EBD process.

Organizations can still choose to join as a Pebble Partner to conduct a scientifically rigorous study surrounding their facility design, but there are also new options for participants who may need support for other initiatives. Consistent with the general structure proposed by Kirk Hamilton in his 2003 paper Four Levels of Evidence-Based Practice, the Pebble Project recognizes that the interests, goals, and organizational capacity may vary between projects, providers, and design teams.

Some may want to use available evidence to stay up-to-date, interpret meaning, and develop tangible examples. Others may hypothesize outcomes and measure results using a less subjective design.

Still others may want to subject their study to scrutiny, while a smaller group of scholar practitioners strive to publish in peer-reviewed journals or collaborate with academics where their work is subjected to the highest level of rigorous review.

With this in mind, the Pebble Project is now open not only to healthcare providers and industry partners, but to architecture and design firms that have a specific project for consideration.

Architects and designers have always been an integral part of Pebble research, providing insight on the problems being addressed and the specific built environment solutions proposed. Increasingly, healthcare organizations have been more formally including their architecture and design firms in their Pebble Project initiatives.

With the option of becoming a Pebble Partner, architects and design teams can provide additional leadership roles during the planning, construction, and remodeling project throughout all project phases of the EBD process.

New Pebble Partners have the benefit of attending bi-annual Pebble Colloquiums that not only highlight work of the Pebble Partners, but also provide access to site tours and “deep-dive” sessions into topics such as emergency department design, Lean processes, and the multitude of transition planning considerations.

While they learn more about the Pebble Project in this early stage, they work with CHD to choose a more focused topic of inquiry.

This can include a literature review related to a design decision; a CHD-led preoccupancy checklist review of the project; a post-occupancy review conducted by CHD staff using a standardized evaluation tool; a pilot study to evaluate a design feature;  a study to fill a gap related to a priority research topic defined by CHD and its volunteer-based Research Coalition; or a customized, high-level, high-engagement research initiative for organizations committed to pushing the design paradigm envelope and integrating EBD into the facility lifecycle design process.

Pebble Partners have access to quarterly issue papers that address timely topics or respond to questions from the Pebble community, and they have the opportunity to participate in grant-funded research (such as the U.S. Green Building Council grant to develop an open-source database for environmental safety issues [RIPPLE] or the Agency for Healthcare Research and Quality grant for designing for patient safety).

Partners that find they need additional assistance can also choose supplemental services to support their work. This may include additional consulting time with the CHD research team, industry expert consulting services in specialty areas, assistance with understanding and disseminating results, writing for magazines or journals, or providing support with institutional review board (IRB) applications.

This flexibility allows for many types of organizations to contribute to the body of knowledge in myriad ways, while lea
rning from a group of like-minded peers who want to improve both the quality and safety of healthcare, while increasing efficiency, satisfaction, and bottom-line results.

The Pebble Project is part incubator and part accelerator, where partners come to the collaborative with their goals, questions, and challenges; share and learn from the experiences of counterparts around the country and world; and, with guidance from The Center for Health Design’s consultants and research staff, develop strategies to implement, measure, and document the results of their endeavors whether the quality of care, environmental safety, patient safety, worker safety, or the financial performance of the institution.

Provider organizations range in type, size, and location and include large and small acute care hospitals; academic, research, and teaching institutions; ambulatory care facilities and clinics; specialty hospitals (e.g., pediatrics, cancer, residential care), health systems; and government authorities.

With the wide variety of project-specific options, and the ability to customize a program, the Pebble Project offers different avenues that allow engagement at varying levels of the EBD process. Organizations that join might be looking to distinguish themselves by increasing their research visibility and dissemination or by employing evidence-based design practices into their work.

Others join once they have committed a portion of their staff to become EDAC-certified in order to further advance their knowledge, as well as their contributions to the industry. Whether the interest is contributing to the body of knowledge through topic-focused learning, having access to standardized tools, or conducting rigorous research, Pebble Project membership may be an option to advance your use of evidence-based design.

Ellen Taylor, AIA, MBA, EDAC, is Director of Pebble Projects for The Center for Health Design.

Berry, L., Parker, D., Coile, R., Hamilton, D. K., O’Neill, D., & Sadler, B. (2004). The business case for better buildings. Frontiers in Health Services Management, 21(1), 3–21.

Hamilton, D. K. (2003). The four levels of evidence based practice. HEALTHCARE DESIGN, 3, 18–26.

Taylor, E. (2011). How Are You Using Evidence-Based Design? HEALTHCARE DESIGN, 11, 128-139.