Having an MRI can be a frightening experience, typically requiring patients to enter a small, enclosed space inside a machine that produces loud clicking or beeping noises as its magnetic fields alternate. Patients are also required to stay completely still, adding to potential stress and anxiety caused by fears related to enclosed places, pain, the unknown, or what the test might reveal. Research shows that more than 30 percent of patients undergoing MRIs experience some form of anxiety. Overall, the patient experience can be less than ideal and is often exacerbated by poor facility conditions, such as lackluster waiting spaces. In addition to their impact on the patients, these conditions can also have operational implications, such as increased sedation, premature termination of the procedure, longer-term MRI fears, and motion artifacts (when patient movement disrupts the process, which yields cost factors related to medication use and repeat scans).

At Parkland Hospital in Dallas, where an MRI department is utilized by both Parkland and its teaching hospital affiliate, UT Southwestern Medical Center, there are two waiting rooms that serve four magnets, seeing approximately 25 inpatients and 25 outpatients a day. Average wait time for outpatients is between 30 to 45 minutes. During this time, patients wait in a windowless, mixed-gender waiting environment in their hospital gowns. Family members sit in the same room. Furniture has limited flexibly and is fixed against the wall, and the area lacks positive distractions. Long, barren corridors lead to the MRI procedure rooms.

Currently undergoing a massive replacement project, Parkland wanted to explore the financial and operational value of interior design elements beyond the usual idea of aesthetic appeal. In this vein, Parkland engaged American Art Resources (Houston) and HOK Architects (New York) in conducting a research study that investigates the impact of design in the waiting environment. They did so with the goal of using this research to inform the design for the new hospital and to contribute to the wider field of healthcare design. The project delves into both inpatient and outpatient experiences, where outpatient approaches focused specifically on the hospital’s MRI suites.

Research design and methods
The study had two phases: Phase 1 was designed to establish a baseline for the existing facility and to develop the design for an art and furniture intervention, and Phase 2 tested the design intervention and reported the findings. Validated instruments were used to measure such health issues as the anxiety levels of patients and visitors and patients’ fear of MRI procedures, and operational outcomes including patient sedation, motion artifacts, time to complete a successful scan, and premature termination of MRI. Additionally, customized questions on the waiting experience and feedback on the environment, furnishings, and art were asked. Patients filled out three surveys: The first was completed before the MRI procedure, the second immediately after the procedure, and the third weeks after the procedure. Visitors also responded to a survey as they waited for the patient. Lastly, the MRI technicians who monitor the patients during the procedure filled out a survey during the MRI.

The study was designed in such a way as to allow this process to be repeated independently by the hospital staff in the future. The information was collected using a relay system in which patients were given a packet during registration that contained all the surveys. Patients, visitors, and technicians self-administered the survey so that no onsite researcher was needed. Two students from the healthcare administration program at University of Texas at Arlington were used to oversee and observe the process, and to help troubleshoot any issues related to the self-administration process. They didn’t interact with any of the respondents.

The surveys and overall process were pilot-tested to evaluate the process and validate the tools, with subsequent updating based on the results. In Phase 1, a total of 320 patient surveys, 277 technician surveys, and 150 visitor surveys were collected over a period of two months. Feedback from the surveys informed the selection of art and furniture for the Phase 2 intervention. New art was installed in the waiting rooms and the hallway leading to the MRI, and new furniture was installed in two identical waiting rooms. After the change, surveys were collected again for a period of two months and resulted in 226 patient surveys, 136 technician surveys, and 94 visitor surveys. The drop in response rates in Phase 2 was attributed to new registration staff and processes resulting in added paperwork. This also resulted in increased wait time and procedure time in Phase 2, which could have mitigated some of the effects of the environment. Qualitative feedback revealed a certain level of “survey fatigue,” with patients reporting being tired of filling out paperwork.

Findings
The two-year study resulted in a large amount of data, triangulating the patient experience from different perspectives, and at different points of time, encompassing both health and operational outcomes. Some key findings include:

  • Patients’ pre-procedure anxiety was lower in Phase 2 (post-intervention) as compared to Phase 1. This was arguably the result of an improved environment and waiting experience.
  • In Phase 1, pre-procedure anxiety was significantly higher than the anxiety post-procedure (after the MRI scan) for patients. However, in Phase 2 (after the art and furniture were installed), the difference between pre- and post-procedure anxiety was not significant. This implies that the while the waiting environment helped to reduce pre-procedure anxiety, this effect did not continue for anxiety experienced by the patient during the entire visit.
  • No significant differences were found in the operational outcomes (time in scanner, premature terminations, etc.) between Phase 1 and Phase 2. This suggests that to improve the operational outcomes during the imaging procedure, a more immersive intervention that addresses patient experience, before, during, and after the procedure is warranted.
  • Patients reported on their anxiety before and after the procedure, and were then surveyed weeks later via a mail-in survey and asked to recall the level of anxiety they experienced pre-procedure, during, and post-procedure on their last visit. All three ratings of anxiety in the mail-in survey correlated to the post-procedure anxiety reported on the day of the MRI. This suggests that patients “recall” their anxiety based on how they feel after the procedure, rather than before. For visitors, ease of finding the MRI center was highly correlated to ratings of cleanliness, privacy, aesthetic appeal, quality of care, and overall rating of comfort. This implies that wayfinding and approach may have a significant impact on how satisfied family members accompanying the patient are with the physical environment.

Revelations and next steps
Comments from patients about the kind of art they like revealed a strong preference for both landscape and floral imagery. This was in line with the evidence base on the appropriateness of nature images for areas with vulnerable patients. Based on the study and a literature review, guiding principles for Parkland’s art program include the use of evidence-based art in all high-stress patient areas. Additionally, the needs of varying patient populations have been considered in the selection of art throughout clinics and bed units, resulting in a highly individual
ized art program rather than one that’s generic or "one size fits all.”

And while waiting is an integral part of the healthcare experience that must be addressed, findings suggest that care should also be taken to enhance the MRI experience itself as well as the post-procedure environment, which is often overlooked. To this end, Parkland is looking toward its new facility as a way to focus on each step in the imaging process, with consideration paid to both patients and visitors accompanying them. Parkland will invest in wayfinding to ease navigation to the MRI department, also providing expanded parking and valet.

Overall, this study was able to not only investigate the impact of the environment but also create a method for data collection that’s sustainable and replicable, and can be administered by the facility independently and at different points of the project lifecycle. The survey toolkit that addressed the continuum of care (before, during, immediately after, and weeks after the procedure) from multiple perspectives (patients, staff, and visitors) allows a comprehensive approach to studying patient experience that can potentially be modified for use across different populations and settings.

 

Gena English, AAHID, EDAC, RAS, is senior program manager NPH FF&E/interior designer, Hospital Replacement Program Parkland Hospital in Dallas, and can be reached at gena.english@phhs.org; Kathy Hathorn, MA, EDAC, is CEO and creative director, American Art Resources in Houston, and can be reached at kathy.hathorn@americanartresources.com; Robyn Bajema, EDAC, is research project manager, REDCenter at American Art Resources in Houston and can be reached at robyn.bajema@americanartresources.com; Erin Peavey, Assoc. AIA, LEED AP BD+C, EDAC, is researcher and medical planner at HOK in New York and can be reached at erin.peavey@hok.com; and Upali Nanda, PhD, Assoc. AIA, EDAC, is chair, advisory council, REDCenter at American Art Resources in Houston and Vice President and Director of Research at HKS Inc., and can be reached at Upali.nanda@gmail.com.

Acknowledgments: Nick Watkins, Scott Cummins, Jodi Donovan, Yuland Tyner, and Kathy Harper.