When a hospital patient is also a guest

As patients lie in their hospital beds, hardly a sound enters their private rooms from the hive of activity outside, thanks to noise-reducing rubber floors, walls and doors configured to muffle sound, and sound-absorbing ceiling panels.

Sunlight filters through translucent shades rolled down for privacy. The bathroom is a few steps from the patient's bed, rather than across the room, saving a patient from having to navigate obstacles. These are standard patient rooms in the Lunder Building at Massachusetts General Hospital in Boston.

Consider the alternative. Ellison, an older Massachusetts General building, has harsh fluorescent lighting and drab yellow walls. The hallway intercom blares every few seconds, and the door to the supply closet across the hall from patient rooms clicks each time a nurse punches in the key code. Each patient room has two beds, so patients hear their roommate's coughs, wheezes and groans. The clatter of feet and the din of the voices of staff and visitors continuously assault patients' ears.

The gap between these two experiences is the focus of growing attention, as hospital systems work to improve the patient experience. Experts say happier patients are healthier patients, and that hospital stays should be restorative, not dehumanizing and exhausting.

Hospital leaders are keenly aware that enhancing the patient experience has the potential to lift their bottom lines. A sign of the growing interest in this area is the widespread emergence of chief experience officers at a growing number of health systems.

"The focus on improving the experience is clearly everywhere," said Dr. Jim Merlino, president and chief medical officer at Press Ganey, who previously served as the Cleveland Clinic's chief experience officer.

But hospital leaders differ sharply in how they define the patient experience and how they prioritize their improvement initiatives, leading to a clash within the industry. Should such efforts focus on aesthetics or on clinical processes and communication? Or, should it marry the two? And how should the patient experience balance clinical care—giving a patient the care they need, even if it's unpleasant—with amenities, such as better parking or luxury toiletries?

Dr. Ashish Jha, a professor of health policy at the Harvard School of Public Health, fears that hospitals are too focused on superficial aspects of patient experience. Hospitals are "wasting a lot of resources doing things that are not particularly important," such as artwork and parking, which they think matter for patient experience, Jha said. Yet, "what we know is that patient experience scores are not going up," he added.

The lack of a widely agreed-on definition of patient experience is "one of the most frustrating topics in the entire industry," Merlino said. "I think that hurts our ability to improve."

Many hospitals and health systems treat the patient experience as a matter of improving the customer service experience. Merlino considers that flatly wrong. "The service piece is a component of it, but it's not the primary piece," he said. Instead, he prefers Press Ganey's definition of a good patient experience as safe, high-quality healthcare delivered in a compassionate, empathetic environment.

The Beryl Institute, which focuses on improving the patient experience, defines it as the "sum of all interactions, shaped by an organization's culture, that influence patient perceptions across the continuum of care."

The myriad ways healthcare organizations focus their efforts on the patient experience reflect the range of definitions. Some are renovating and redesigning entire buildings. Others focus on improving communication. And some work on both.

The concept of consumer experience applies differently in healthcare than in other industries. "At the end of the day, it is about having better health outcomes and well-being for people," said Joan Kelly, chief patient experience officer for NYU Langone Health System in New York City. "The reality is, people don't choose this. They only want to use it when something is wrong. It's very different from a purchasing mindset."

The goal in designing Massachusetts General's Lunder Building, which opened in 2011, was to streamline workflow and care delivery for providers while being mindful of the needs of patients and their families, said Joan Saba, a partner at architecture firm NBBJ and the lead architect of the building. Its major design elements reflect that, with use of noise-reducing materials, adjustable lighting, and rooms and doors angled to give patients greater privacy.

Instead of forming a ring of patient rooms around a cluster of workstations, or loading corridors on both sides with patient rooms, Lunder's floor plan resembles two letter Cs facing each other but shifted so their termini don't align, Saba demonstrated with her hands.

Patient rooms are located along the Cs, with service and support rooms stationed in the curve of each, mitigating the issue of staff congregating in a single noisy nursing station. A central diagonal spine shortens travel distances around the floor.

For improving the patient experience, "the private rooms are key," said Susan Cronin-Jenkins, co-director of real estate and facilities at Massachusetts General. "If I have two patients in a room, every time I take care of one, the other patient usually asks for something. So that's more time away from doing what I need to do. It adds staff time and disruption to the patients."

Additionally, a 2016 study in the Journal of Critical Care found that the cost of building private rooms can be offset by reducing hospital-acquired infections. The study, however, only focused on the intensive-care unit.

The feel of Lunder contrasts sharply with that of Ellison in other ways. At Ellison, hallways are cluttered with mobile computer workstations. Nurse desks and supply rooms are located directly across from patient rooms.

"All this stuff makes noise," said Cronin-Jenkins, swiping her ID badge to demonstrate the clicks and pings that accompany opening the supply closet door. "If you're across the hall and you're trying to sleep, it's very disruptive."

The noise level is 10 to 15 decibels lower in Lunder than in Ellison. Higher noise levels in hospital rooms have been linked to disrupted or poor-quality sleep, which can delay a patient's recovery.

The differences between Lunder and other buildings are reflected in patient-satisfaction scores. Patients staying in Lunder consistently respond more positively on the Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS, than do patients who received care in other Massachusetts General buildings.

"By looking at the scores, you can guess where it is. (Lunder) is a better place," said David Hanitchak, vice president for real estate and facilities at Massachusetts General. Employees prefer Lunder too, he added.

Healthcare has followed other industries, such as retail and tech, in focusing on customer experience.

One factor driving this is that patients are taking more control over where they get their care because of the rise of high-deductible health plans. Patients paying more of their own bills out-of-pocket are more likely to decide where they can get the best value.

The introduction of the HCAHPS survey, which asks Medicare patients to grade hospital cleanliness, communication and other elements of their experience gave patients a chance to tell hospital leaders what they really thought of their stay. The CMS began requiring hospitals to collect and report this information in 2007. In 2008, the CMS began publishing HCAHPS results.

HCAHPS is just one piece of the broader transition to value-based payment. The Obama administration set the goal of tying 90% of spending in the traditional Medicare program to value by 2018, through a mixture of alternative payment models, quality measurements and financial penalties and incentives. Private insurers are attempting to do the same.

Medicare's new value-based physician payment system is also prompting the increased focus on patient experience.

"As insurance companies are starting to move from pay-for-volume to pay-for-value, part of that value equation is the patient experience," said Scott Perra, CEO of Mohawk Valley Health System, an integrated delivery system in upstate New York. "If you didn't have reason to work on it before, you have reason to work on it now."

Mohawk Valley Health is planning a new, 750,000-square-foot campus, designed by NBBJ. Patient experience was one reason for upgrading from its two current buildings, which are 60 and 100 years old.

Frank Beaman, CEO of Faith Community Hospital, a 41-bed facility in Jacksboro, Texas, with a Level 4 trauma center and a rural clinic, said he's keenly aware that enhancing the patient experience can be powerful in protecting or boosting market share, even in a rural area where the closest competitor is 35 miles away.

In 2015, Faith Community opened a new hospital. It has separate entrances for different departments, making navigation easier and more convenient. And it includes the Faith Cafe, which Beaman said has become a destination for the community.

Overall, staff should be courteous, the hospital clean and the landscaping well-groomed, said Beaman, who refers to patients as "guests." The hospital also has focused on speeding up billing and registration processes. "We don't want anyone to have to wait more than 10 minutes," he said.

On the clinical side, patients can fill out a 45-second experience survey on an iPad before they leave. Giving patients that outlet has helped pre-empt angry patients who can easily "vomit all over social media," Beaman said. In a small community, such complaints resonate.

NYU Langone Medical Center built the luxurious Tisch Elevator Tower after Superstorm Sandy wrought nearly $1 billion in damage at the hospital in 2012. Its interpretation of patient experience blends the aesthetic, the structural and the clinical.

The system is building new units and facilities, such as the 830,000-square-foot Kimmel Pavilion, which will be the only hospital facility in New York City with private rooms when it opens next year. Renderings promise spacious lobbies full of commissioned artwork, New York-themed pediatric waiting rooms, and private rooms outfitted with 74-inch flat-screen monitors.

At the same time, the hospital is painstakingly redesigning clinical processes under the eye of Chief Experience Officer Joan Kelly. She works with a team of patient experience designers examining every step in the care process, looking for weak points from both the patient's and the clinician's perspectives.

A visual designer maps every step in the care process and produces large flowcharts featuring arrows and color-coded bubbles. This inventory discovered the startling fact that some patients received 41 separate pieces of paper before even receiving a primary diagnosis. "It's overwhelming," Kelly said. "You can't manage that."

When the team looked at how providers communicated with patients, they realized the process was almost like a police interrogation. Patients saw a slew of different providers, each of whom went over the same questions, which patients had to answer again and again.

With these discoveries in mind, Kelly and her team came up with patient-centered solutions. For instance, NYU Langone has developed booklets, in hard copy and digital formats, to guide patients through the course of treatment, for instance listing everything a surgical patient should know. That includes what to expect from surgery, how to prepare for it, what happens after surgery, what exercises to do, and questions to ask the doctor.

For hospital staff, Kelly's team designed a training program called Patient Experience 101. Over two years, the entire NYU Langone staff-17,000 people, including nurses, physicians, housekeeping staff, and food services-went through this training, which pushed them to always consider the patient's perspective.

At the Cleveland Clinic, a 14-hospital system, the range of patient experience initiatives is broad. In one initiative, it tapped famed fashion designer Diane von Furstenburg to create a more dignified medical gown.

"The experience of putting on a gown is exceptionally dehumanizing," said Dr. Adrienne Boissy, Cleveland Clinic's chief experience officer. "Ultimately, she produced a gown that wrapped around so that nobody's backside was hanging in the wind."

Several years ago, the Cleveland Clinic started putting its providers through a relationship-centered training program. That resulted in a statistically significant improvement in the "respect" domain of the organization's HCAHPS score, as well as improvements among physicians on measures of empathy and burnout.

Many healthcare leaders hope that improving the patient experience will help move healthcare away from the sterile impersonality of modern medicine and back toward a strong relationship between patients and providers marked by kindness and caring.

"You don't need expensive technology or training to be empathetic and compassionate. You just need to be present and in the moment," said Press Ganey's Merlino. "It's easier than people think. It's just about getting back to the basics."