What got us thinking… Patient experience is a driving factor for the healthcare industry. Organizations are measured and reimbursed on how well they deliver patient experience. In an effort to increase their scores, many healthcare organizations have focused on renovated or redesigned patient rooms or clinical spaces. But they’ve overlooked critical spaces like waiting areas, unwittingly undermining their other efforts to deliver better experiences by coming up short from the beginning of the patient journey. As empowered patients have more choices about where to receive care, every facet of their experience must be maximized – including transition spaces. So we wondered: Can improved transition spaces positively influence patients’ experience? Turns out is the answer is yes.
Waiting rooms, at their worst, can look and feel like holding pens, designed to seat the most patients in as little room as possible, providing few physical or emotional comforts. At their best, these spaces can offer a smooth transition from physical pain and emotional uncertainty to vital information and relief.
Unfortunately, the experience is less than optimal at many healthcare facilities today.
Imagine it’s mid-afternoon in the waiting area of a large medical clinic. The door that leads to patient care areas quietly opens and 30 pairs of eyes dart expectantly, hoping to hear their name called. The announcement is made, one name is called. Looks of disappointment and anxiety are exchanged. An older woman gathers her belongings that are spread out over a couple of chairs. She rises slowly, obviously in pain, and walks to the door, unsure of how her appointment will go.
On one side of the room, a family is trying to find space to gather and talk about questions they have for the doctor. They’ve moved toward a corner to find some privacy, but chairs are lined up in orderly rows from end to end, preventing them from being able to look at one another. Some sit, some stand, but no one looks comfortable.
A television mounted on the wall flashes cable news with the sound turned down so low it’s barely audible. A young man tries to balance his laptop on some magazines and juggle his mobile phone in an attempt to make more productive use of his time.
This familiar scene plays out across the globe every day at healthcare facilities of all sizes.
Unfortunately today, this is the reality many patients face as they wait. Wait to meet with a care provider. Wait to learn a diagnosis. Wait to receive information. And the places where they wait – whether for minutes or hours – are all too often unpleasant and unappealing. Patients are left lacking – lacking privacy, information, storage space, and access to technology. In these environments, the waiting room experience contributes to low expectations for the quality of care patients may receive from clinicians.
And that is both a problem and an untapped opportunity.
The Increasing Emphasis on Patient Experience
Measuring patient experience isn’t a new practice – it’s been standard operating procedure for decades. But what’s relatively new is the shift to a new measurement model – the Hospital Consumer Assessment of Healthcare Providers and Systems survey (HCAHPS) developed by the federal government’s Health and Human Services Department (HHS). Patients complete a 32-question survey and HHS bases 30 percent of hospitals’ Medicare reimbursement on their scores.
Patients are asked about their experiences ranging from staff responsiveness, quality of care transitions, clear communication about medication, as well as cleanliness and quietness of the facility.
Results are publicly available on a website – www.medicare.gov/hospitalcompare – and hospitals are ranked on a five star system, a practice that only started in April 2015. When the first rankings were released, only 251 of 3,500 participating hospitals received the highest rating – five stars. More than 1200 hospitals received a 4-star ranking, 1414 scored 3-stars, 582 placed in at 2-stars, and the remaining hospitals only managed one star.
Not only does the federal government rely on these results to determine reimbursement levels, some insurance companies do as well. In addition, some hospitals are basing staff pay levels on the results. There’s a lot riding on the findings.
And they’re about to get even more important.
In 2017, the one percent withheld from hospitals for Medicare reimbursements – approximately $850 million – will double to two percent. Only hospitals with high patient satisfaction scores will earn that money back, and top performers will earn bonuses from a pool.
As financial pressure stiffens and empowered patients begin to act more like choosy consumers, healthcare organizations are looking for ways to nudge their patient experience scores higher. Competition in the healthcare marketplace is a full-blown reality, as consumers have more choice and more comparative information at their fingertips.
Responding To The Pressure
In 2001, an arm of the National Academy of Sciences called The Institutes of Medicine released a pivotal book, Crossing the Quality Chasm: A New Health System for the 21st Century. The authors called for a systemic reinvention that would “require a fundamental, sweeping redesign of the entire health system.” They identified six aims for improvement to deliver healthcare that is:
In addition, they established ten rules for redesign that continue to influence today’s strategies for improvement:
- Care is based on continuous healing relationships
- Care is customized based on patient needs and values
- The patient is the source of control
- Knowledge is shared and flows freely
- Decision making is evidence-based
- Safety is a system property
- Transparency is necessary
- Needs are anticipated
- Waste is continuously decreased
- Cooperation among clinicians is a priority
This trumpeting call for change, combined with increasing government and insurance company reimbursement requirements, sparked significant hospital investments mostly to improve in-patient rooms and clinician space. New patient towers were erected, and hospitals began to tout their facilities in addition to their clinicians as a competitive advantage.
Recommendations emerged on how to improve scores and hospitals paid attention. They added valet parking, expanded meal selections and quality. They’ve added live music and flat screen televisions. A handful offer VIP lounges for their “loyalty club” members.
But at the majority of hospitals, waiting rooms are decidedly not VIP Lounges.
And for most hospitals, this is an opportunity waiting to be leveraged.
Phase One: Observations
Much has been studied, written about, tracked and trended about patient experiences – but there have been very few conversations about the impact of space on perceptions of quality care. Patients want the best care, but often find it difficult to understand the differences in qualifications and expertise of individual staff members, clinical teams and overall healthcare organizations. While patients have more access to rankings, comparisons and data than ever before, it’s still hard to know what doctor or organization is best for them. So they rely on their experiences and judgment instead. They may not know an organization’s percentage of mortality and morbidity, but they often look to more subjective measures they understand – like whether they feel listened to, comfortable, and if the environment was pleasant.
This realization that space beyond clinical care areas and patient rooms can influence satisfaction scores brings the importance of well-designed transition areas into stark relief. This expanded definition of patient experience is no longer contained to just interactions with clinicians – it’s the entire journey – including what happens in the transition space.
Steelcase Health researchers connected the dots and wondered if supportive transition space design would be reflected in measures of patient experience. We partnered with a major academic medical center in the southeastern United States to conduct several days of observations to understand the current realities of waiting rooms. Using proven research methods, Steelcase researchers observed and captured more than 75 behavior maps of patients and families over five days in the pre-study waiting room setting.
Specifically, the researchers aims were to:
- Identify seat choice, family group sizes and grouping patterns
- Understand family needs and expectations to determine potential furniture and process changes
- Examine the relationship between environmental variables and patient experience.
Across the board, Steelcase Health researchers identified four common mistakes in transition space design. Today’s waiting rooms generally feature:
- Not enough chairs with direct sight lines to information sources
- No room to place personal items or technology devices
- Not enough separation from strangers; no intentional group space for families to gather
- Chair configurations for large groups, rather than typical groups of 1-2
Based on these observations, the opportunity to transform dull, uncomfortable transition spaces into welcoming ones appears to be one that could deliver immediate results. “Supportive transition spaces provide spatial separation and information for patients and their families,” said Michelle Ossmann, director of health environments for Steelcase Health. “We’re working with health care organizations to create spaces that accommodate a range of activity preferences, integrate technology and information sharing, and create an emotionally supportive environment. Transforming waiting into productive time makes the experience more meaningful and helps prepare patients for the next step in their journey.”
Three guiding principles that should influence healthcare design as medical organizations rethink their transition spaces:
- Balancing sight lines
- Rethinking density
- Creating separation and togetherness
In many waiting rooms, views to the outside and windows have been the traditional emphasis. While natural lighting and views are important, Steelcase researchers observed people orienting themselves toward information sources instead – wanting to see and hear the clinician call their name or see a status update on a monitor. Understanding this balance of sight lines between information and views to the outdoors creates the need for new ways of arranging seating and placing monitors. “Information can be the antidote to anxiety in waiting areas,” Ossmann said. “People are afraid to miss important information from healthcare providers.”
Seating density, often the primary concern for waiting rooms, is getting a fresh look as well. Steelcase Health researchers noted that only 80 percent of occupied chairs had people sitting in them– the remaining chairs held personal items or drinks, confirming decades old research on seating preferences. By creating small group seating and accommodating storage, fewer seats are required for patients and their families – saving space and reducing financial investment while creating opportunities to deliver more patient value. “This isn’t about packing the most people in the waiting room,” Ossmann says. “It’s about responding to their behaviors in a more intuitive way – a way that helps relieve some of the stress of being at a medical facility. Simply giving people some additional physical space also gives them additional emotional space.”
Steelcase Health researchers also observed that people prefer to be separated from strangers and yet close with family members. People even created work-arounds in the space to suit their differing social or privacy needs. But here’s the current reality: waiting room design emphasizes individual seats next to each other, often in long, continuous lines. Designers and facility planners are often told how many chairs to plan for, and therefore respond with the most efficient layout – lining chairs up in uninterrupted rows. To achieve a balance of separation and togetherness, they can create zones that allow families and individuals different spaces to support their preferences and behaviors – ranging from family conversations to privately engaging with an electronic device to resting and reading. “When you’re faced with a medical issue, privacy is a big concern,” Ossmann says. “By providing for auditory and visual privacy, we’re supporting patient and family needs at the most fundamental level.”
Just ask Ken Hutchenrider, president of Methodist Richardson Medical Center in Dallas, TX, who opened several new transition spaces in 2014. “Going into this project, waiting rooms were not something we were focusing on or we thought would be a feature, and that would receive as much praise, but it’s turned out to be such a major element in this new hospital,” he says. “Our new waiting rooms are by far one of the best features of our new hospital.”
Phase Two: The Delta
The second phase of our research involved creating more engaging transition spaces in one of our partner’s clinics – a specialty clinic that sees approximately 27,000 patients each year. Often, the clinic sees an average of 100 patients and family members a day, and wait times vary from 30 minutes to several hours. Because the clinic’s patients are immuno-suppressed, safety is of paramount importance.
Based on our recommendations, the clinic’s transition spaces were transformed through a combination of new furnishings and the creation of distinct zones. Due to wall configurations, we needed to keep some long rows of seats, but we
- Added lounge seating – with wider seats with wider armrests
- Included double seats to create social opportunities and encourage family groupings
- Installed chairs that feature a slight rocking movement and supplemental physical support for post-operative patients
- Augmented a coffee space with a round café table
- Moved seating for optimal sideways views instead of out the windows or directly at staff areas
- Provided plugs in seating bays for easy technology access and charging
- Featured tables with space dividers for additional privacy
- Used easily wipeable coverings for improved cleanliness
Phase Three: The Results
The post study was completed in October 2015 by observing, mapping and interviewing patients and their families in the clinic’s updated waiting space.
In the pre-occupancy study, Steelcase Health researchers observed:
- 20% of occupied chairs taken up by bags and drinks, not people
- Occupancy of sideways facing seats was 57% higher than window facing seats and 32% higher than desk facing seats
- Occupancy of desk facing seats was 38% higher than window facing seats
- 28% engaged with screens
- 8% read a book
- 5% interacted with people outside their family group,
- 3% talked on cell phone
- 3% slept
- 2.6% did paperwork
- 0.4% wore headphones
In the post occupancy study, Steelcase Health researchers observed:
- 16% of occupied chairs taken up by bags and drinks, not people
- Occupancy of sideways facing seats was 39% higher than window facing seats and 22% higher than desk facing seats
- Occupancy of desk facing seats was 21% higher than window facing seats
- Group sizes: 52% in Groups of 1; 43% in Groups of 2, 3% in Groups of 3, and 1% in Groups of 4.
- 24% engaged with screens.
- 3% read a book,
- 7% interacted with people outside their family group (but 75% of those interactions were with clinicians),
- 21% were not engaged in any activity
- 24% interacted with family members
- 1% talked on cell phone
- 3% slept
- 6% did paper work
- 1% wore headphones
Behavior mapping results
Gains Across the Board: Improved Privacy and Storage
Improvements in Comfort and Pleasantness
Pleasantness: Technology, Power and Information Access
Results clearly show that patients prefer the updated waiting room on multiple metrics. The updated design showed:
- Increased comfort levels
- Greater ability to perform activities
- Easier access to power and technology
- Additional speech and visual privacy
- Added pleasantness from furniture, flooring, lighting, color scheme and pictures
“We expected to see some positive movement,” says Ossmann. “The results we’re seeing show we’re moving in the right direction. We view these newly updated waiting areas as a potential competitive advantage for our customers and a more pleasant experience for patients. The changes we made appear linked with perceived environmental quality. Updating transition spaces is a very achievable change to make and delivers valuable results almost immediately.”
The Next Chapter in Patient Experience
As pressure ratchets up for healthcare organizations to deliver increased patient experience, few systems are leveraging the full power of space – particularly transition spaces – to help increase perceptions of quality of care.
Now, with the support of a body of research suggesting a link between transition spaces and perceptions of quality care, facility managers and designers are seeing the hidden potential transition spaces represent – and are taking action. No longer can the waiting room take a back seat to clinical spaces as contributors to patient experience. The time to rethink waiting rooms is now.
Steelcase Health researchers have found that supporting physical and psycho-social needs and space design are linked with positive experiences, a key metric for today’s healthcare organizations. This insight offers practical implications: well-designed waiting experiences that decrease stress and promote active engagement can help improve patient experience both during waiting and subsequent care encounters. With pressure mounting to deliver more patient-centered care and better experience scores, progressive healthcare organizations are already leveraging their transition spaces as a competitive advantage, and seeing positive results.
The evidence is in: Better waiting rooms simply can’t wait.