As healthcare facilities designers, our mission is to improve the physical environment for patients, families, and caregivers. But, often, we lack the rationale to make our case to hospital leadership. Sometimes there are programmatic and operational justifications for conceiving new projects. Sometimes we can prove, through evidenced-based research, that an improved environment can create better clinical outcomes. But is there just as strong a justification to improve the physical environment to enhance the patient and family experience?

The most interesting data to come out of the 2010 HealthLeaders Media Patient Experience Survey was that nearly 93% of the top-level U.S. healthcare executives say that patient experience is among their top five priorities, and more than one-third say it is their top priority.1 Yet how the physical environment improves the patient experience is one of the hardest things to quantify. One approach is to look at the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, an important quality management tool, and see how we as healthcare facility designers and planners can help hospitals score better outcomes and, ultimately, better financial success.

For years, the healthcare design industry has tried to convince healthcare clients that improving the physical environment of care is good for business. In a competitive environment, we promoted the marketing advantage of having the most up-to-date amenities and hotel-like or home-like environments. This followed the accepted practice, in most service industries, that the most appealing packaging will lure customers: in this case, both healthcare providers and consumers.

Marketing research shows that a new facility almost always brings a "bump" in business, at least until the next "latest and greatest" appears in the market. Since so many factors affect healthcare choices, including physician practice patterns and insurance coverage, this strategy was successful to a point, but was not completely quantifiable.

How patients perceive their hospital experience has become a more important issue for U.S. hospitals since 2007, when the Centers for Medicare & Medicaid Services instituted the Inpatient Prospective Payment System annual payment update provisions. Under these provisions, those who participate must report quality measures or annual payment updates will be reduced by 2%.

One required quality measure is the administration of the HCAHPS (pronounced H-Cap) survey. HCAHPS is the first standardized, publicly reported survey of inpatients’ perspectives regarding their hospital stay. This was based on three goals: to allow meaningful comparison of hospitals for consumers, to create incentives to improve the quality of care, and to improve accountability of public investments in hospitals.

The intent of the HCAHPS initiative is "to provide a standardized survey instrument and data collection methodology for measuring patients’ perspectives on hospital care." This creates a national database created from a 27-question patient survey administered between 48 hours and six weeks following discharge to those randomized patients who have stayed at least one night in the hospital.

"The HCAHPS survey contains 18 patient perspectives on care and patient rating items that encompass eight key topics: communication with doctors, communication with nurses, responsiveness of hospital staff, pain management, communication about medicines, discharge information, cleanliness of the hospital environment, and quietness of the hospital environment."2 The results are then publicly reported in 10 categories and are publicly summarized on the Hospital Compare website ( for individual hospitals or at HCAHPS online ( for state and national statistics. In July 2010, 3,774 hospitals had publicly reported results.

Here is a brief synopsis of the type of questions asked:

Care from nurses and doctors: Did they treat you with courtesy and respect? Listen carefully to you? Explain things understandably? Give help promptly?

• Hospital environment: Was your room cleaned often? Was it quiet at night?

• Hospital experience: Did you get adequate help using the bathroom? Was your pain well controlled and were medicines explained?

• Leaving for home: Were you adequately informed and prepared for going home?

• Hospital rating: How do you rate your experience and would you recommend the hospital?

• Personal description: Health, education, descent, race, language.

So can one measure how the physical environment improves the quality of experience for patients and family? What aspects of hospital design and planning could directly impact the answers from patients listed above? A study reported in Health Care Management Review in 20033 looked at creating a business case for more appealing healthcare settings. The premise was, "Do patients in appealing rooms more favorably evaluate healthcare providers and services than do patients in typical rooms?"

The study looked at the perception of care in two adjacent inpatient unit settings—one old and unrenovated, and one in a new building. The study tried to duplicate clinical operations and patient type as close as possible to eliminate variables. The conclusion reached was that though the clinical care was almost identical, the care was perceived as superior in the newly constructed facility. If this is indeed the case, then HCAHPS scor
es should get a boost from well-designed facilities where the physical environment enhances how staff is perceived.

Let’s look at how improving the environment can be justified to improve HCAHPS scores:

Care from doctors and nurses:

Many of the HCAHPS questions deal with enhanced communication between clinicians and patients. There are many ways this can be improved by the physical setting in active and passive ways. Better nurse call systems that allow for direct contact to the assigned nurse reach help faster. Bedside location of computers allows for direct eye-to-eye communication while recording patient information. Private patient rooms afford a quieter, less-distracting environment than multi-bedded rooms. Decentralization of nurses to be closer to the patient room can facilitate direct patient interaction on a more regular basis.

Quiet at night:

Research is now indicating that same-handed rooms are even quieter than mirrored private rooms, since they don’t share headwalls or entryways.4 This also will improve sound transmission at night, affecting sleep. Placement and enclosure of clinical coordination areas (formerly called central nurse stations) can reduce noise transmission. Use of sound-absorbent materials can vastly improve acoustics.

Hospital experience:

The design, size, and proximity of toilet rooms to the patient bed can greatly affect how easy it is for patients to use the toilet on their own or if they are in need of assistance. A toilet room with adequate clearances for patients, IV poles, and accompanying staff afford a more pleasant experience for the patient. Larger doorways and barrier-free showers help patients and staff. Additional grab bars strategically located between the bed and toilet, and adequate floor lighting allow a patient to get to the toilet unassisted, even at night.

Though the administering of pain medication can be considered a clinical operations issue, the perception of pain or discomfort can be altered by environmental strategies. Studies by Roger S. Ulrich and others have shown that more views to nature and natural light can reduce the amounts of pain medication requested.

Leaving for home:

When family members participate in patient care at the hospital, this increases their medical understanding and improves their ability to assist patients upon returning home. Families can be supported by allowing space and furnishings for overnight stays in patient rooms and by providing food on demand. Private consult areas with more comfortable furnishings can facilitate communication. Some facilities have also instituted "discharge lounges," where discharge information can be discussed in a less-hectic setting.

Staff disposition:

At the 2010 Patient Experience Summit at Cleveland Clinic in Ohio, research was presented showing that happy, engaged caregivers lead to more satisfied patients. Designing staff off–stage support spaces with natural light, comfortable furniture, and healthy food service and exercise options can improve the work environment by lessening fatigue. The residual effect could be more courtesy and respect afforded to patients and family.

The HCAHPS and other quality measures must be publicly reported to maintain baseline Medicare funding. Consumers can now judge hospitals against rankings of other peer institutions in their region. As competition becomes keener, a good patient experience will become even more important, leading to further recommendations to other patients, families, and caregivers. This will provide even more justification for improvement of the physical environment in all healthcare settings. HCD

Sheila F. Cahnman, AIA, ACHA, LEED AP, is Group Vice President/Regional Practice Leader—Healthcare at HOK. She can be reached at


1. HealthLeaders Media, Intelligence Report: Patient Experience. (accessed October 21, 2010).

2. Centers for Medicare & Medicaid Services. (accessed November 20, 2010).

3. Swan, J., Richardson, L., Hutton, J. Do Appealing Hospital Rooms Increase Patient Evaluations of Physicians, Nurses and Hospital Services? Health Care Management Review, 2003. 28(3) 254-264, Lippincott Williams & Wilkins, Inc.

4. "Getting Nurses Back to Patient Care: Nursing Unit Design, Informatics, and Clinical Outcomes", 2010 ANCC National Magnet Conference, Mary Kennedy, RN, MS and Maria Ducharme, MS, RN, NE-BC, The Miriam Hospital, Providence, RI, Nicholas Watkins, PhD, HOK