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Nightingale also described the importance of structuring hospitals around nursing care. The initial design of hospitals followed that advice by building large wards where nurses could easily monitor and observe their patients. Later, hospital design evolved to placing patient rooms surrounding centrally located nursing stations. Then, as today, the physical environment of hospitals can create stress for patients, their families, and clinical staff. Research is finding links between the physical environment and patient outcomes, patient safety, and patient and staff satisfaction (Hamilton, 2003). Studies show that such elements of hospital design as exposure to natural light, private rooms, and facilities that are staff friendly and have less noise contribute to improved patient outcomes (Ulrich, Quan, Zimring, Joseph, & Choudhary, 2004).

Although little is known about how to best design the hospital environment to facilitate clinical advances and care delivery, an estimated $200 billion will be expended for new hospital construction across the United States during the next 10 years (Institute of Medicine (IOM), 2004a). The Robert Wood Johnson Foundation (RWJF), the nation's largest philanthropy devoted exclusively to health and health care, has provided funding to the Center for Health Design, a nonprofit research organization, for the Designing the twenty‐first Century Hospital Project, which is the most extensive review of the evidence‐based approach to hospital design ever conducted. Launched in 2000, the Pebble Project is a joint research effort between the Center for Health Design and health care providers. The project engages health care providers that are building new health care facilities or renovating old ones using an evidence‐based design. The project uses the latest available evidence to inform design innovations and then measure the outcomes of the innovations through carefully designed research projects. The results are shared with the larger health care community to promote change. The Pebbles Project is an example of facility design to improve quality of care (The Center for Health Design, 2011).