Pebble Partner Affinity Health System's St. Elizabeth Hospital, located in Appleton, Wisconsin, applies Lean principles to identify and eliminate waste, evidence-based design (EBD) practices to enhance the patient experience, and sustainable criteria to design and build environmentally friendly buildings. All three concepts-Lean, EBD, and sustainable design-are required to help carry out Affinity Health System's promise of personalized care of listening, treating patients with respect, and putting their needs and interests first. As part of implementing evidence-based design in a renovation of the Emergency Department (ED) waiting room, Affinity Health System selected a new acoustically absorbing wallcovering product to use on the ED waiting room walls. To evaluate the effectiveness of this approach, Affinity partnered with fellow Pebble Partner Johns Manville and product manufacturer SoundTech to measure both the acoustical change in the room and the perceived noise and privacy from patients, families, and staff in the ED.

Acoustics in healthcare-What are the issues?

Noise in healthcare facilities is a major cause of stress for patients and a negative distraction for caregivers (Bayo, Garcia and Garcia, 1995; Blomkvist et al, 2005). According to David Sykes, cochairman of the International Workgroup on Healthcare Acoustics, Speech Privacy, and LEED, “noise is the number one healthcare complaint and noise in hospitals is twice what it was just two decades ago”. According to the World Health Organization, the guideline values for continuous background noise in patient rooms are 35dBA (A-weighted decibel) during the day and 30dBA during the night, with nighttime peaks in wards not to exceed 40dBA (Berglund et al, 1999). Alarmingly many studies have actually found background noise levels in hospitals to be 72dBA during the day and 60dBA during the night (Bush-Vishniac et al, 2005).

The Pebble Project creates a ripple effect in the healthcare community by providing researched and documented examples of healthcare facilities where design has made a difference in the quality of care and financial performance of the institution. Launched in 2000, the Pebble Project is a joint research effort between The Center for Health Design and selected healthcare providers that has grown from one provider to more than 45. For a complete prospectus and application, contact Mark Goodman at

In emergency departments, noise can be an even larger issue. Higher overall noise levels have been measured in EDs than in inpatient care units in several studies (Orellana, Bush-Vishniac, and West, 2007). One study conducted at Johns Hopkins Hospital in Baltimore, Maryland, revealed higher overall noise levels in the ED than the inpatient care units and pointed to the potential impact of noise upon patient safety in the ED, as well as privacy concerns with patients disclosing information to caregivers (Orellana, Bush-Vishniac, and West, 2007). It has been identified that ED staff spend 80% of their time communicating verbally (Vincent and Wears, 2005) and perceptions of privacy within the ED environment may affect patient disclosures to caregivers which could impact ED patient diagnosis and care (Barlas, 2001).

Acoustical materials for healthcare are generally readily available, and include ceilings and carpeting, with very little acoustic treatment typically applied to walls, due to infection control, cleanability, and durability concerns. Products and/or materials for the ceilings and floors alone will often not achieve the desired overall noise reduction. The wall space must also be addressed.

Collaboration leads to great results

Affinity Health System wanted to study the highest level of acoustical control by using the appropriate materials on the floor, walls, and ceilings. The ED waiting room was selected for an acoustical test due to the high volume of patient traffic and sensitive nature of the patient information communicated in and around the room and that the results of this pilot study would inform the larger renovation that is currently underway (a new emergency department). Interior finish changes completed in the ED waiting room included new ceiling tiles with an acoustical performance rating of NRC 0.70; a flooring change from carpet to vinyl; and a thin, cleanable, acoustical wallcovering was applied to all the walls.

The effect of the changes in interior finishes on the acoustical environment was determined by measuring the reverberation time in the ED waiting room before the renovation, at various points during the renovation, and at completion. Reverberation time is a measure of how long a sound lingers in a room, reflecting from the various room surfaces. Long reverberation times can contribute to increased noise levels in a space and to a reduced sense of privacy. A local acoustical and audio/video consultant, Arrow Audio, was contracted to perform the measurements. The satisfaction levels from both patients and staff perspectives were studied by administering a survey before and after the renovation to patients and families in the ED waiting room and to the ED admissions staff. The survey questions asked respondents to rate various aspects of the acoustical environment in the ED waiting room.

Despite the noticeable improvement in the acoustical environment in the ED waiting room, the results of the reverberation time measurements were not conclusive. This could be due to several reasons, including the uncontrolled presence or absence of chairs in the space and a large opening from the waiting room into a corridor, among others. It was unfortunate that the measurements did not reflect the experience of persons in the room, but this can be a risk in field testing. The survey results, however, indicated that occupants of the waiting room could detect a difference that the acoustical measurements could not. Patients, families, and staff were asked questions related to the noisiness of the room and their perceived privacy in the room. Comparing postrenovation responses to prerenovation, the responses improved on all measures, with assessments of noise level in the waiting room and feelings of privacy in the waiting room improving by statistically significant amounts.

Staff, physicians, and patients have all made comments to the difference in the overall acoustical quality of the area. According to Gary Kusnierz, “Having a solution that you can actually hear the difference is a very positive outcome”.

Moving forward

For Affinity Health System, this information was instrumental in the overall understanding of acoustical design. Performing acoustical analysis before and after each of our major projects is something we now employ. The findings from this study not only helped the remainder of the design in renovating the emergency department but also in the design of a new Heart Center. Currently underway is the postoccupancy acoustical analysis of the Heart Center. Based on the collected acoustical data and comments, a combination of proper flooring, wall, and ceiling materials will provide the best outcome.

At Affinity Health System, it is strongly felt that through these acoustical pilot tests we now have the critical data needed to reduce noise pollution, which in return will have a significant impact on the patient experience. Building upon our hypothesis-that proper flooring, wall, and ceiling materials will have a significant impact on the patient experience-thin, cleanable, acoustical wallcoverings will be applied in a functioning patient room at Affinity Health System's St. Elizabeth's Hospital. The reverberation time in the patient room will be measured before and after a sound absorbing finish on up to two walls has been applied. A patient room offers a more closed, controlled environment in which to evaluate the acoustic benefit of treating the walls with a sound absorbing finish. The results of this pilot study will be presented at the Acoustical Society of America meeting in Baltimore, Maryland, spring 2010, in a special session focused on healthcare acoustics. HD

Gary Kusnierz is the Vice-President of Performance Excellence, responsible for strategic policy deployment, Lean deployment, design, development, and construction, for Affinity Health System. Francis (JR) Babineau, PE, is the Indoor Environmental Quality Leader in the Corporate R&D group at Johns Manville (JM) and serves as the JM representative to the Pebble Project. Chuck Hogan is the Market Development Manager for SoundTech, Inc. Healthcare Design 2010 February;10(2):14-15