In 2004, the United States spent more than $16 billion for hospital construction, an amount that is forecasted to rise to more than $20 billion by 20101 A significant proportion of this construction is for ambulatory facilities, marking a major shift from a focus on acute inpatient hospital care to an increasing range of outpatient services.2 With the shift to increased outpatient and ambulatory practices, the types of patient outcome measures affected by facility design have also shifted, to focus more on patients' perceptions of quality and satisfaction. There is growing support for the belief that “as healthcare facilities strive to satisfy their consumers in a competitive healthcare market, attention turns to the patient perceptions of their physical surroundings and how environmental elements affect their healthcare experiences.”3 Our Pebble Report research at the Weill Cornell Medical College's Physicians Organization ambulatory care practices in New York City aims to build on earlier work on waiting rooms in healthcare settings. Some key findings that guided our research include the following:

  • More attractive waiting areas are associated with higher perceived quality of care.4

  • Patients' evaluation of their overall healthcare experience is influenced by their interactions with staff, including staff responsiveness, courtesy, competence, and communication.5

  • The performance and attitude of healthcare staff are, in turn, influenced by the physical environment in which they work.6-8

  • Longer waiting times have a negative effect on overall satisfaction.9 In a study of waiting times in an urgent care department, Dansky and Miles found that total time spent waiting for the clinician was the most significant predictor of patient satisfaction.10 Informing patients how long their wait would be and their being occupied during the wait were also significant predictors of patient satisfaction.

  • Perceived total waiting time was less than actual waiting time.11

Virtually all of the research on patient-centered care to date has focused on inpatient rather than outpatient facilities and services. No studies have examined the ways, if any, in which the attractiveness of the physical setting where the patient waits affects perceived quality of care or perceived waiting times.

The Weill Cornell Medical College Study

Weill Cornell Medical College's Physicians Organization is building a new ambulatory care facility. As a Pebble Partner, Weill Cornell examined the relationships between the attractiveness of the physical setting and actual and perceived waiting times, quality of care, anxiety, and staff-patient interaction in seven outpatient practices, some of which will move to the new ambulatory care building. The research questions were:

  • How much time do patients spend waiting?

  • What is the relationship between actual versus perceived time?

  • What is the relationship between time spent (actual and perceived) and perceived quality of care?

  • What is the relationship between the physical environment and perceived quality of care?

Research Design and Site Selection

Seven clinical outpatient practices located in six facilities within the Weill Cornell Medical Center/New York-Presbyterian Hospital and Weill Cornell Medical College in New York City participated in the study. The facilities varied significantly in overall environmental attractiveness. They also varied within each of the three practices examined—gynecology, dermatology, and gastroenterology. The three less attractive practices were selected because of existing plans to move them into a new 13-story, 330,000-square-foot, $230 million ambulatory care complex currently under construction by Weill Cornell—hence the opportunity to compare the patient-centered design of the new facility with the older, existing facility.

Separate locations within the same healthcare system were chosen in an attempt to control—as much as is possible in any large, complex medical system—differences in staff quality, patient populations, and organizational culture. Four of the practices—the Jay Monahan Center for Gastrointestinal Health (figure 1) and two floors of the Iris Cantor Women's Health Center (figure 2)—were located in independent facilities within a few blocks of the main hospital complex, and the remaining three practices were located in the main hospital complex. All practices included in the study are referral, outpatient practices.

Jay Monahan Center for Gastrointestinal Health. Photo by Jaimie Holmer

Iris Cantor Women's Health Center. Photo by Jaimie Holmer

Physical Environment Ranking

Rankings of the attractiveness of the physical environment were determined by a panel of six Cornell University graduate students in non-design-related fields. This panel compared all of the practices based on multiple photographic images, with no knowledge of the type of practice, staff, or hospital affiliation represented in the photographs. Results from all the subjects were then combined to create an environmental attractiveness score for each location. The theoretical maximum and minimum scores were 36 and 6, respectively, with the higher number reflecting a more attractive environment. Actual rankings ranged from 34 to 9, with a high level of inter-rater reliability (table 1).

Table 1. Rankings of practice attractiveness



Jay Monahan Center for GI Health


Iris Cantor 11th Floor (Gyn)


Iris Cantor 10th Floor (Derm & GI)


J130 Gynecology


J314 Gastroenterology


Starr Dermatology


Data Collection

Data were collected in all practices using systematic observations and a patient satisfaction survey. Observations by research assistants were made over a 13-week period: a total of 9 weeks from May through July 2005 and 4 weeks from mid-February through mid-March 2006. Throughout the study period, 787 patients were observed across all practices in more than 370 hours of data collection. During the same period, 205 patient satisfaction surveys were collected from the seven practices. Four questions on the patient satisfaction survey pertaining to patients' overall experience of their visit were combined to form a perceived quality of care index. An overall staff index was determined using patient responses from four survey questions pertaining to interactions with staff (including nurses, physicians, and reception staff) during the office visit. In addition to the times observed by the research assistant in each location, perceived time was assessed on the patient survey with questions asking patients how long they waited in the waiting area and in the exam room before the doctor entered, as well as questions about their perception of the wait, activities while waiting, and if they felt they had waited too long.

Based on studies showing that there is a significant difference in customer loyalty between respondents who respond with the highest possible rating and those who do not,12 all analyses were based on the percentage of patients who responded with a five (Excellent/Strongly Agree) on a one-to-five scale.

Selected Findings

Environmental Attractiveness. The study showed that the more attractive the environment, the higher the perceived quality of medical care and the greater reported reduction of anxiety. It also showed that the greater the environment's attractiveness, the more positive the reported interaction with staff. Physical attractiveness of the environment had a greater influence on perceived quality and anxiety than actual time spent waiting or time spent with the doctor. Patient perceptions of quality and anxiety relief, feeling cared for as a person, and recommending the office to others were higher in more attractive physical environments (figure 3). Regression analysis showed that the attractiveness of the physical environment influences the patient's perception of quality, and that the perception of care quality then reduces the patient's anxiety level.

Figure 3

Time. Patients underestimated longer (30+ minutes) actual wait times and overestimated short (0 to 5 minutes) actual wait times. No significant relationship between actual wait times and perceived quality, perceived anxiety, or staff interaction was found. Patients' perceived waiting time was significantly related to perceived quality and staff interaction. Time spent waiting in an exam room had a greater impact on the patient's perceptions of quality and staff interaction than time spent in the waiting area. Overall, patients in more attractive environments perceived shorter waiting times than did patients in less attractive environments (table 2).

Table 2. Observed time findings

Observed time findings

Avg (hrs/mins)

Standard deviation

Avg % of total visit

Total time in clinic




Time spent with doctor




Time spent with all staff




Total wait time




Time in waiting area




Time in exam room




Time spent alone in exam room




Time in exam room until Dr. entered




Staff Interaction. In more attractive environments, patients perceived more positive staff interactions than patients in less attractive environments. Patient perceptions of staff interaction were more strongly correlated with feeling cared for as a person, recommending the office to others, feeling welcome, and reducing patient anxiety than with the attractiveness of the environment or perceived quality (figure 4).

Figure 4


This research offers insight into outpatient facilities, a rapidly growing segment of healthcare provision that has received considerably less attention in the research literature than inpatient services and facilities. The findings suggest a number of implications for practice.

First, patients' perceived quality of care and the reduction of anxiety are significantly related to the physical attractiveness of the patient waiting areas. Also, patients' perceived quality of care is even more significantly related to their perception of their interaction with staff. Therefore, an important aim of future research should be to better understand how the physical setting of outpatient facilities influences staff behavior and attitudes and how these behaviors and attitudes, in turn, influence patient perceptions of care quality.

The study also revealed that more attention needs to be paid to both the design of exam rooms and their function, in practice, as patient waiting areas. Patient flow is another aspect that needs further attention, as well as the point at which patients are shifted from a waiting area to the exam room. Ways of reducing the time patients wait for the doctor in the exam room and ways of making the wait more pleasant and productive need to be explored.

Finally, architects, designers, facility planners, and those working directly in medical practices need to pay more attention to how patient areas are designed and used and to the potential for making small-scale, targeted design interventions that could significantly improve the patient experience.

The Weill Cornell Pebble research reported here is being extended, in a second phase, to focus on the relationship between the physical facilities and staff-patient interaction patterns in the existing facilities studied. Phase 3 of this research will collect data on patients and staff following the move to the new ambulatory care facility. HD

Franklin Becker, PhD, is Professor and Chair of the Department of Design & Environmental Analysis (DEA) in the College of Human Ecology at Cornell University. Stephanie Jones Douglass, MS, recently completed her master's degree in DEA and now is a workplace strategy consultant for DEGW in New York City.


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