The Gray Area Of Healthcare Design
U.S. healthcare construction continues to move steadily along at the reliable pace of $38 billion to $42 billion a year. Harder to quantify is the value of healthcare design—particularly its influence on patient satisfaction.
In today’s healthcare landscape, hospitals are under increasing pressure to improve their patient satisfaction scores. These scores are publicly reported by the Centers for Medicare & Medicaid Services (CMS) so patients can compare various hospitals and make informed choices. Moreover, 25 percent of CMS incentive payments to hospitals are linked to the scores.
How are healthcare organizations responding to the pressure? One common belief held by healthcare administrators is that patients who feel positive about a healthcare setting are more likely to be satisfied with the care they receive. Consequently, new construction and renovation have become a key strategy for improving scores.
So it’s no surprise that a study on patient satisfaction conducted before and following a move to a new inpatient facility published earlier this year in the Journal of Hospital Medicine got a lot of attention and gave the healthcare design industry a reason to pause.
A wrench in the works?
Completed in 2012, the Sheikh Zayed Tower is a 355-bed inpatient facility and home to the Johns Hopkins Medicine Heart and Vascular Institute in Baltimore. The building project offered an opportunity for a team of researchers at Johns Hopkins to test the assumption that patient-centered design would have a broad impact on patient satisfaction, including with care delivery. This research team analyzed 5,663 ratings on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Press Ganey surveys. From the statistical findings, the team inferred whether patients’ perceptions of caregivers improved at the new facility compared to the old.
What did the study find that prompted a media stir? For starters, the patients were quite good at distinguishing between their care and the quality of the facility in which they receive care. There was improved inpatient satisfaction with facility-related features such as pleasantness of décor, noise level, visitor accommodations, and comfort. Yet, overall satisfaction scores only increased modestly and care delivery, arguably the mission and heart of any healthcare enterprise, saw no improvement in satisfaction scores.
Taken all together, the Johns Hopkins study concluded that patient-centered design isn’t a panacea and that the prevailing wisdom of assuming a direct and causal link between facility design and patient satisfaction oversimplifies more complex dynamics. Aging facilities should not shoulder full blame for poor patient satisfaction scores and, likewise, a new facility isn’t a magic wand that wishes away fundamental challenges with care delivery. Research and return-on-investment analyses may show it’s wiser for more capital expenditures to be allocated toward operational and training interventions.
Another result of the buzz was a call by some in the healthcare design industry for more research to quantify the value of patient-centered design. How do we take steps in the right direction and are there some useful precedents that begin to untangle the complexity of these relationships?
Not as it seems
Many interrelated factors influence patient satisfaction, and there’s a nuanced interplay among patient satisfaction, patient health, and facility design.
Case in point: research published in Health & Place in 2013 by Claudia Campos Andrade and co-authors explored the relationships among a patient’s status (i.e., inpatient, outpatient), perceived quality of physical and social environment, and satisfaction. The study strongly indicates that inpatients have different expectations and perceptions of their surroundings—and make different types of value judgments about them—as compared to outpatients. The social environment closely associated with caregivers and care delivery was important to inpatients, whereas the aesthetics of the physical environment were more closely scrutinized by outpatients.
As suggested by this and the Johns Hopkins study, there are connections between facility design, inpatients’ experiences, and care delivery that need more exploration. Design research helps us muck around a lot more in these gray areas where unexpected relationships go to hide, such as the influence a waiting area might have on patient’s perception of a physician’s bedside manner or the location of a team station on care coordination.
The elusive connections between design and patient experience can be sought out when design research aggregates a broader spectrum of observed behaviors and outcomes in healthcare settings. Fortunately, a mixture of new and old techniques is helping design researchers revamp the data-gathering process, making it easier to discover more complicated and unexpected patterns.
The two case studies that follow are illustrations of how advances in design research are powerful tools to identify challenges, target real value whether that be patient satisfaction or something else, and ultimately prioritize design and operational solutions so they are aligned with building project goals.
In planning an inpatient and outpatient facility, Cleveland Clinic set out to explore the ways in which the design for an acute care patient room might improve empathic relationships and the patient experience. Cleveland Clinic worked with BBH Design (Raleigh, N.C.) to conduct the design research and WRL Architects (Cleveland) for the design during 2014 and early 2015.
More than 600 Cleveland Clinic patients provided input through an online patient panel survey, while others completed written questionnaires during their hospital stay. Patients and caregivers also took part in a series of mock-up experiments that incorporated multiple and subtle manipulations of room configuration. Finally, the team undertook behavioral observations that were collected from patients, visitors, and clinicians on three existing inpatient units, accounting for the roles of nearly everyone on the units and their activities.
The findings converged on a key theme: Patients appreciated the value of improved design while they also recognized that quality of care was distinguishable from room aesthetics. This echoed the study by the Johns Hopkins team; however, the study also revealed a picture of patients who valued room designs that supported opportunities for more control over the patient room environment, responsiveness by frontline caregivers, and family presence.
Results indicated that patient loyalty improved and anxiety decreased when the patients felt and had more control over room conditions (such as lighting levels). Patient-centric amenities that boosted this sense of control included reading lights, accessible outlets for personal devices, in-room accommodations for family members, opportunities for room personalization, as well as views of artwork and the outdoors.
Many of the patients recognized and valued room features that h
elped caregivers respond to their security and comfort needs. Keeping this in mind, experiments with a same-handed room mock-up demonstrated improved rounding, better visibility, and more reliable knowledge about the location of supplies and equipment.
Similarly, an idea for in-room docking stations for workstations-on-wheels created win-win situations for the patients and caregivers. The orientation of the docking stations encouraged more satisfying face-to-face interactions between patients/family and caregivers, and caregivers could be more efficient by not having to power up their workstations or find a place for documentation in busy corridors.
The design research redefined project assumptions by revealing the underlying issues and aligning design decisions to what patients and their caregivers actually value. An important takeaway for everyone involved was that the design research created opportunities to advance Cleveland Clinic’s facility design that may have not been considered without the design research.
New Parkland Hospital
With an FKP-designed clinic underway for its new campus, the New Parkland Hospital in Dallas conducted a study to explore how clinic design and layout can influence communication and collaboration among patients and caregivers. The hospital partnered with BBH Design (New York and Raleigh, N.C.) and KI (Green Bay, Wis.) to conduct five days of behavioral observations, ethnographic observations, and team interviews on two existing outpatient clinics in spring 2014
The behavioral observations found some meaningful relationships between design and caregivers’ communications with patients. For example, one challenge found in the existing space was that physicians and nurses spent much of their day in front of computers—even in the exam rooms—which limited face-to-face communication with patients and fellow team members. Also, nurses were the “glue” to the clinics, searching for others and resources and relaying information between physicians and patients.
Location, accessibility, visibility, and team composition also came into play. Interdisciplinary team stations boosted collaboration and opportunities for nurses to interact with and find physicians, particularly in one highly visible and accessible work area located at the intersection of two main corridors. A station located further offstage, however, was much less likely to be used by caregivers.
Furthermore, it appeared to the data collectors that the out-of-the-way team stations may have partially accounted for crowding in exam rooms by patients waiting to be discharged, as they may have simply been “out of sight, out of mind” for team members using those offstage locations.
The design research team next facilitated a series of design charrettes with the clinics’ nursing staff, providing the opportunity to generate ideas for exam rooms, workstations, and floorplans. After an initial review of the research findings, the participating nurses dove into the charrette exercises and devised several design solutions that were different from their current clinics.
One solution to enhance team-based care was a “provider corral” with standing-height desks for nurses that are off the main corridors and circle around an interdisciplinary team station. With this concept, the nurses hoped to keep tabs on physicians’ whereabouts without being intrusive and be closer to their patients.
Several exam room layouts were also proposed, such as an “around-the-clock” arrangement, literally placing the patient at the center of care delivery within the rooms, visible at all times to the caregiver. While not all ideas for the exam rooms were adopted for the new clinics, several were and others will be considered for future projects.
By performing participatory exercises guided by the research findings, the nurses experienced a fresh perspective on their current operations and design. Halfway through one session, a nurse commented on how her team was recreating their present condition and how they needed to switch gears to something more innovative. Such “aha” moments empowered the nurses to consciously recognize their current challenges and be motivated to recommend novel design concepts.
Out of gray and into light
The above case studies are from institutions undertaking design research to address unanswered questions relevant to their needs. The findings aren’t currently available in peer-reviewed sources and shouldn’t be generalized.
However, the process involved is encouraging. The case studies reveal and prioritize the underlying problems and value-added design solutions that mattered for the unique needs of each organization. They drill deeper into assumptions of patient-centered design, discovering relationships that inform and redefine prevailing assumptions for improving patient satisfaction and building project goals.
For example, research shows at Cleveland Clinic that cozy-appearing patient rooms and at Parkland that offstage team stations may not be key drivers to improved HCAHPS scores or patient experience, and may be of low priority or even problematic.
Far from discouraging, the above provides ample opportunity for designers and healthcare organizations to target real value for design interventions. Efforts to collect more and the right type of data may quantify links between design interventions, patient satisfaction, return on investment, and other outcomes. Evidence that supports investment in expensive facilities should be evaluated with the same high standards and rigor as other healthcare-related decisions.
For administrators and caregivers, these examples illustrate the need to be less reactive to the ticker tape of HCAHPS scores and to support research initiatives that can identify design solutions that will bring value.
Design researchers should also step up to collaborate with frontline providers and leading healthcare quality and satisfaction researchers to broaden the study of outcomes that are most meaningful to the patients and for clinical outcomes—research that may even discover that a design intervention isn’t the best bang for the buck or part of the solution.
This concept shifts design research to the front-end of building project delivery, to target design goals that provide the greatest return on investment before the predesign phase. In the future, requests for proposals, budgets, and schedules should have preliminary design research and integrated teaming as a given.
Nicholas Watkins, PhD, is a director of research with BBH Design. He can be reached at firstname.lastname@example.org. Zishan Siddiqui, MD, is an assistant professor and attending physician with the department of medicine of Johns Hopkins University. He can be reached at email@example.com.