Walk into many of the new hospitals in the United States, and you might mistake the lobby for that of a five-star hotel. Between the beautiful atria, private inpatient rooms, and modern décor and furnishings, hospitals have eliminated a good part of the sterile atmosphere that often intimidates visitors and patients.

But with this new trend toward hotel-like surroundings, amenities, and even services come numerous questions, concerns, and challenges. Do these features increase costs for the hospital and its patients? Do these amenities affect patient outcomes? Are we setting unrealistic standards moving forward? As the country enters an unprecedented period of healthcare reform, it's worth examining what's happening with this hotel model in the United States and how patient room design is evolving in other parts of the world.

Focus on the family

The trend toward more accommodating inpatient rooms and service amenities seems to stem, in part, from the values found in family-centered care. Since the early 1990s, such organizations as the Institute for Family-Centered Care and The Center for Health Design began to formally focus on gathering research supporting evidence-based design, including the role of the family in a patient's recovery. As studies began to reflect a positive relationship between family involvement and patient outcomes, more hospitals began designing patient rooms to include space and amenities to accommodate loved ones, such as pull-out beds, workstations, and other features. At the same time, research also indicated that private rooms help keep infection rates down. With private rooms came more options for including the family, and thus the family-centered model truly emerged.

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The recent practice of some hospitals to outsource their housekeeping and food services to hospitality vendors may be tied to patient satisfaction surveys that often showed low marks for food quality, room cleanliness, and other personal comfort expectations. Hospitals have on occasion enlisted hospitality-focused vendors to help improve those scores. As a result, not only are these hospitals providing more personal amenities like newspapers, expanded menus, and Internet access, but even the language used to discuss those features has shifted to a hospitality lexicon. Housekeeping, food service, and linens turn-over have become “room service,” “hospitality,” and “linens valet.” And as family members become additional “guests” in the room, these amenities are often extended to them as well, including concierge services in the lobby.

Of course, one of the most influential factors in the implementation of these models in the United States may be the open-market healthcare system itself. With more Baby Boomers spending time in healthcare facilities with aging, ill parents or as patients themselves, these features, comforts, and accommodations are becoming a clear preference. And, as in any competitive system, if two healthcare providers are comparable in most measurable ways, the intangibles and the opportunities for customer control and choice may help to sway decisions.

The pros and the cons

The family-centered focus and the subsequent upgraded patient experience have their benefits. According to a 2009 article in Health Environments Research and Design Journal, many patients feel more comfortable and comforted when family members are nearby and involved in their care (Pati, et al). And with the family more actively included in the care routine, they're likely to become more educated about the patient's treatment plan and recovery process. The family learns how to help care for their loved one with hospital staff supervision and then can take that knowledge home with them. Similarly, having extra sets of hands in the room can help the nursing staff manage the many tasks and demands of daily patient care. As the 2006 Time magazine cover story (Gibbs, Bower) explains, many doctors agree that patients need someone to remain in the room and serve as a “sentinel,” asking questions and watching over treatment.

On the other hand, accommodating family may have unintended consequences. In terms of patient care, more people coming in and out of a room can introduce increased chances for infection. Accommodations may also include additional harder-to-clean surfaces and materials in comfortable couches, workstations, and other amenities. Sharing responsibility for care is also a concern; what happens when nursing staff are not in the room but added “guests” are tending to those patients? Are we seeing the need for care partner waivers?

Another concern is the increasing distance between patients and exterior windows as “family living” space expands and room depth continues to creep outward. We have been learning that patients' improved exposure to daylight can help reduce their length of stay, but with more couches, lounge chairs, desks, and other trimmings, patients' beds are often moving farther and farther away from the window. Are we compromising the patients' recovery in favor of the family and visitors?

From an operational efficiency point of view, the disadvantages could also pile up quickly. A larger room may mean longer distances between nursing staff, patients, and supplies, and more space for outside “stuff” to make its way in (personal belongings, food, gifts, etc.). And with more people filling the room, more demands are put on staff, from care-related questions to requests for reading materials, snacks, or other needs. A room that was once designed for one patient to enable their return to health must now often accommodate four or five people at any time of day with their own individual activities and needs.

This is the challenge of embracing the family-centered, hotel-style inpatient hospital room. While having the family present and involved in their loved one's care clearly helps some patients with long-term recovery and can assist the nursing staff with small tasks during their stay, they can inadvertently put incremental strain on care delivery.

Traveling abroad

In other areas of the world where government-guided healthcare prevails, this dilemma hasn't emerged in the same way it has in the United States. In Can
ada, for instance, the super-sized family zone is rare. Inpatient rooms are still relatively basic yet modern; the space between the patient's bed and the window typically accommodates a medical recliner for overnight visitors or at most a pull-out bed.

In many areas of Europe, room “amenities” are focused more around patient control and comfort than on the proximity of family. In newer hospitals in Denmark and the Netherlands, for example, a swing-arm held computer with keyboard provides what is essentially a “control center” allowing patients to adjust room lights, open and close windows and blinds, order meals, access educational resources and watch television. At Orbis Medical Center in Sittard-Geleen in the Netherlands, the bedside computer/control center allows patients to open and close their sliding room door and permits staff access to their patients' records.

As in Canada, the family zone in Europe tends to be relatively limited within the patient room, but often close by are very well-appointed patient/family lounges. At Orbis, the patient room access corridor itself has become the lounge, with real wood floors, modern domestic-styled furnishings, an island nourishment center, and, with most staff charting done at the bedside, only a couple of small staff work desks. Many European hospitals offer families lodging in on-site hostels rather than providing in-room accommodations for their extended stay.

The best of both

In the Middle East, however, the current trend in hospital design is shaping a “hospital city,” where they offer it all: high-end design, top-quality care, and as many patient amenities as can be incorporated into massive, multimillion-square-foot complexes. This freedom comes in large part from the region's seemingly unlimited construction budgets. Often funded by the government, either directly or through foundations, new Middle Eastern hospitals fully embrace the five-star hotel, resort-like design model. Inpatient rooms are almost entirely private, lighting is multilevel and accessible, and the family zone often includes plush couches, desks, lighting, wall fixtures, and other features. Some facilities have even incorporated an a-la-carte meal system that uses smaller kitchens on patient floors for more “on demand” or hotel-like room service.

Many of these hospitals also include a number of “VIP” rooms and even whole floors dedicated exclusively to dignitaries. These suite-like facilities often feature several private rooms, servants' quarters, kitchens, board rooms, and prayer rooms, making them suitable spaces to resume normal life and work activities throughout recuperation.

This dedication to generous space and amenities is largely influenced by the need to accommodate the entourage that often accompanies a patient. As evidenced by the VIP suites, some patients bring not only members of their immediate family with them, but also extended relatives, household staff, or business associates. And even “average” Middle Eastern patients expect their relatives to be with them every step of the way. This access is not up for debate; in their culture, the family-or the entourage-is simply part and parcel of the patient's stay and involved from the moment the patient arrives to check out.

The entire check-out process, in fact, is quite similar to that of a hotel. Patients are escorted to a large check-out lounge where their bags are delivered to them, their driver is summoned, and refreshments are available. The process is nearly identical to that of a high-end hotel. A benefit of this system is that housekeeping staff no longer has to wait for the patient to check out before turning over the room. Rather, the patient relaxes in the check-out lounge while staff immediately prepares the room for the next patient.

The big unknown

Clearly, the model employed at many new Middle Eastern hospitals won't become the worldwide design template. But as the United States prepares to revamp its approach to healthcare, it's still largely unknown if our trend toward luxury and hotel-like amenities will survive.

The ongoing and welcome inclusion of family in a patient's recovery may help hospitals reach the anticipated no-readmissions goals of new healthcare legislation. With larger rooms that allow the family to be more involved in a patient's care, patients and families become more educated and practiced in the treatment and recovery process, presumably helping avoid a return. Infection avoidance measures will still remain a critical concern, which could lead to more family education about transmission risks and handwashing monitoring. Fortunately, recent reports have emerged indicating that hospital-acquired infection rates have dropped due in part to this vigilance.

So a balance must be struck. The patient must remain the focus even as the family is welcomed to participate. If we can truly extend the caregiver's limited valuable time and attention through reliance on the family-centered tenets of active participation, then providing well-appointed, highly functional and flexible, but modestly scaled, family spaces and amenities will find justification. With these objectives in mind, let us use judicious restraint moving forward and encourage our healthcare providers to follow through on their commitment to engage the family in the care process. HD

Acknowledgment

The authors would like to thank Ray Pradinuk and Alice O'Connor of Stantec for their contributions on trends in Europe and the Middle East, respectively.

Architect and principal Collin Beers, AIA, and senior interior designer Jennifer O'Shea, ASID, are healthcare design specialists in the Philadelphia office of design firm, Stantec. Stantec has designed hundreds of hospitals across North America and in the Middle East.

References

1. Gibbs N, Bower A. “ Q: What Scares Doctors? A: Being the Patient.” Time Magazine, April 23, 2006.
2. Pati D, et al. “ A Multidimensional Framework for Assessing Patient Room Configurations.” Health Environments Research and Design Journal, Vol. 2, No. 2, Winter 2009, 88-111.

Healthcare Design 2010 October;10(10):58-64