This article was originally published on May 28, 2014, and is among Healthcare Design's Top 10 most-read articles of 2014. To see a full list, click here.

Patients’ healthcare experiences are largely driven by their clinical outcomes, their interactions with staff, and their perceptions of care. How and when the physical environment improves the patient experience is one of the hardest things to quantify.

In a 2012 Healthleaders Media survey, 82 percent of healthcare executives surveyed said expanding or renovating facilities was an important patient-oriented tactic but most are spending 5 percent or less of their operating budgets on patient experience initiatives. Can we build a case that the physical environment can improve the quality of experience for patients and family? A 2003 study in Healthcare Management Review concluded that when clinical care was almost identical, care was perceived as superior in newly constructed facilities.

Enhancing the patient experience has become a top priority since the Centers for Medicare & Medicaid Services (CMS) began linking reimbursements to the HCAHPS, the first standardized, publicly reported survey of inpatient’s perspectives regarding their hospital stay. As consumers can now meaningfully compare hospital ratings online, the significance of patient satisfaction has soared. Additionally, it’s anticipated that CMS will implement the CGCAHPS survey, a standardized tool  that also measures patient perceptions of care in outpatient settings.

The HCAHPS scoring is based on seven key issues: Communication, quiet at night, information about medications, discharge information, cleanliness, responsiveness, and pain management.

New facilities almost universally equal higher HCAHPS scores, but there’s plenty that can be done by making tweaks to existing spaces, too. The following explores what aspects of hospital design and planning can directly impact key elements that support a positive patient experience.

Noise reduction
The physical environment can a play a major role in reducing noise levels to improve sleep and mood, and create better pain tolerance. Private inpatient rooms reduce exposure to noise levels that can cause stress and negative health effects. Research in a 2011 issue of the Journal of Nursing Administration reported that same-handed patient rooms—where all patient rooms are identically oriented—also reduce noise transmission by avoiding shared headwalls and providing more space between patient room doors.

In inpatient environments, specifically, there’s a continuing dichotomy between necessary visibility into rooms for caregivers and acoustical privacy. Patient satisfaction is driving more attention to placement of work areas related to patient rooms as well as sound attenuation.

The Facility Guidelines Institute’s Guidelines for Design and Construction of Health Care Facilities, starting in the 2010 edition, call for minimum acoustic standards at a much higher sound attenuation rating for walls and ceilings in patient treatment areas compared to other spaces. In addition, operational initiatives and implementation of technology like noise detectors to modify staff behavior can be successful, though problems persist related to noise generated by medical equipment and communications systems. Patient calls and alarms guided directly to clinician’s handheld devices can be used to reduce some ambient noise.

Improved communication
The discharge process and communications in general can be enhanced by creating spaces where instructions can be easily and comfortably transmitted to patients and their families. These can include niches where staff and families meet in an informal yet acoustically private setting outside of patient rooms, or formal consultation rooms where more serious discussions can take place. Directions regarding treatment can be more fully comprehended in a relaxed setting created with comfortable furniture and furnishings.

Technology is a key driver of enhanced communications, too. Digital screens deliver patient and family education, wayfinding, clinical communication, and even personal greetings. These can be located in inpatient rooms or exam and treatment rooms, and in the future may be tied to telemedicine for remote consulting. Patient status boards for surgery or interventional patients can be distributed throughout a hospital so families can move freely but still track progress of their loved ones.

Staff support
The Beryl Institute has reported that regular, scheduled rounding by key clinical staff improves outcomes, and perceived staff responsiveness is one of the most important patient satisfiers. Further, responsiveness is improved if charting is done while staff is facing the patient and family. The continuing adoption of electronic health records allows for more decentralized charting, either at the bedside or just outside patient or exam/treatment rooms, bringing caregivers closer to patients. Adoption of handheld devices will accelerate this trend.

To enhance communication among caregivers, smaller, strategically placed “huddle rooms” allow for interdisciplinary clinical meetings closer to patient beds, while decentralizing patient supplies nurse servers located outside patient rooms can also reduce staff travel distances.

Supporting the emotional state of clinicians to best deal with difficult situations is an important piece in creating the best patient experience. Respite rooms can permit staff to be “off stage” when emotional, especially in high-stress departments. Additional amenities such as s staff lounges with natural light, views, and exterior access as well as on-site fitness centers allow caregivers spaces to decompress.

Stress reduction
Introduction of natural light and views of nature, even via virtual reality, can reduce the perception of pain, according to a 2008 report in the Pain journal. Early studies by Roger Ulrich and others showed that pleasant exterior views can help reduce patient length of stay, and it’s now well accepted that natural light uplifts patients, family, and staff, regardless of location within a hospital. When this can’t be accomplished naturally, the use of art or digital monitors depicting nature and faux lighting elements can be very effective. The future may even bring virtual reality “headsets” to the table, providing healing images in place of a real environment.

An additional approach to reducing stress in the hospital environment is to alleviate anxiety often exacerbated by poor wayfinding. Clear, coherent circulation with orientation to the outdoors can be reinforced by color and finishes that designate which corridors are public ways versus staff areas. It’s important that patients and family can see where they need to travel when they first arrive and are guided through the facility by a hierarchy of spaces. Most important is how patients are directed upon arrival.

A generational approach
Meeting the expectations of patients and families becomes even more complex as each generation is considered. Recent consumer research has shown that those born
after the baby boomers are much more computer savvy and self-research their potential healthcare providers, relying more heavily on the patient experience reported by others. Millennials (those born after 1982) are far less likely to choose their care site by physician recommendation and are more likely to respond to branding and amenities provided. So far, healthcare organizations have predominately focused on appealing to older generations who are by far the largest consumers of health services, especially in acute care settings. But as younger generations begin to take on caregiver roles for parents and grandparents, they’ll likely demand more service, communication, and a satisfying physical environment.

Experience mapping is one technique that can be used to understand each generation’s journey through the healthcare setting. During early design for the Park Nicollet Women’s Center, AECOM worked with clinicians and administrators to identify personas of four key patient types: young professional women, young mothers, middle-age menopausal women, and the elderly. The effort illustrated how each patient journey through its new facility was different. A work session mapped each persona’s projected encounters, identifying points of common interaction and potential space conflicts. This not only helped reconfigure the planning but identified key opportunities for art and specialty furniture/lighting placement to enhance the patient experience.

New insights
Improving the patient and family experience in all healthcare settings is only going to gain importance as consumers become more educated on their choices. Social media now only allows users to rate health outcomes but provides a platform to share experiences—both good and bad. Understanding what environmental elements provide the most effective use of resources to improve patient satisfaction will be important in an age of diminishing revenues. The future will bring new insights on the power of design to enrich the lives of patient, caregivers, and staff in healthcare organizations.

Sheila Cahnman, AIA, ACHA, LEED AP, is vice president and healthcare market sector leader at AECOM (Chicago). She can be reached at sheila.cahnman@aecom.com.

Sidebar:
For resources to help guide designing for patient experience, see the following:
Patient experience organizations

  • The Beryl Institute
  • Association for Patient Experience (Cleveland Clinic)
  • Samueli Institute
  • Institute for Patient- and Family-Centered Care

Patient experience initiatives

Noise reduction/patient privacy                                                                                    

  • Lin, Y. K., & Lin, C. J. (2010). Factors predicting patients’ perception of privacy and satisfaction for emergency care. Emergency Medicine Journal (28).
  • Watkins, N., Kennedy, M., Ducharme, M., & Padula, C. (2011). Same-handed and mirrored unit configurations: Is there a difference in patient and nurse outcomes? JONA: The Journal of Nursing Administration, 41(6), 273-279.
  • Ulrich, R. S., Zimring, C., Zhu, X., DuBose, J., Seo, H., Choi, Y., & Joseph, A. (2008). A review of the research literature on evidence-based healthcare design. Health Environments Research & Design Journal (HERD), 1(3), 61-125.
  • Janssen, P. A., Klein, M. C., Harris, S. J., Soolsma, J., & Seymour, L. C. (2000), Single Room Maternity Care and Client Satisfaction. Birth, 27: 235–243.

Responsiveness of staff/staff support/effective rounding

  • Rodriguez, S. (2013). Patient experience: Perception is everything. Hospital Peer Review, 38(7), 76-78
  • Blakley, D., Kroth, M., & Gregson, J. (2011). The Impact of nurse rounding on patient satisfaction in a medical-surgical hospital unit. MEDSURG Nursing, 20(6), 327-332.

Discharge process/communication

  • Ying, H., Becker, F., Wurmser, T., Bliss-Holtz, J., & Hedges, C. (2012). Effects of nursing unit spatial layout on nursing team communication patterns, quality of care, and patient safety. Health Environments Research & Design Journal (HERD), 6(1), 8-38.

Stress reduction/pain management

  • Malenbaum, S., Keefe, F. J., Williams, A., Ulrich, R., & Somers, T. J. (2008). Pain in its environmental context: implications for designing environments to enhance pain control. Pain, 134(3), 241.
  • Altringer, B. (2010). The Emotional Experience of Patient Care: a Case for Innovation in Health Care Design. Journal of Health Services Research & Policy, 15(3), 174-177.

Generational expectations/amenities

  • Williams, K. C., & Page, R. A. (2011). Marketing to the generations. Journal of Behavioral Studies in Business, 5(1), 1-17.
  • Goldman, D., & Romley, J. A. (2008). Hospitals as hotels: the role of patient amenities in hospital demand (No. w14619). National Bureau of Economic Research.
  • Swan, J. E., Richardson, L. D., & Hutton, J. D. (2003). Do appealing hospital rooms increase patient evaluations of physicians, nurses, and hospital services? Health Care Management Review, 28(3), 254-264.
  • Goldman, D.P., Vaiana, M., & Romley, J.A. (2010). The emerging importance of patient amenities in hospital care. The New England Journal of Medicine, 363 (23), 2185-2187.
  • McCracken, L., Pickens, G., Wells, M. (2009) Thompson Reuters Research Brief: Matching the Market: Using Generational Insights to Attract and Retain Consumers