Beyond Surveys: How Human-Centered Standards Can Improve the Patient Experience in Healthcare

While traditional surveys have long been used to gauge patient satisfaction, these snapshots of patient interaction provide a limited perspective on patients’ holistic experience, which includes staff interactions, stress levels, ease of access, family inclusion and the comfort of physical space. As healthcare organizations look to align the design of physical space with the most important drivers of patient experience, human-centered standards are emerging as a valuable tool that underpins a more systematic approach for seeking continuous improvement.

Faced with tight budgets, limited capital and rising costs, implementing human-centered standards may feel easier said than done for many healthcare organizations. The right approach, however, offers a targeted method for improving the patient and family experience while improving efficiency and reducing costs.

This white paper provides a guide to patient experience standards as they relate to physical spaces and the built environment. Beginning with a definition of human-centered experience standards, it proceeds to explore why instituting standards is so pivotal for the continuous improvement of patient and family experience.

The Current State of Healthcare

The healthcare industry continues to place greater emphasis on quality of care and patient-centric models, a shift driven directly by a growing recognition that healthcare outcomes are shaped by a number of factors beyond clinical treatments. As traditional fee-for-service models begin to shift toward value-based care, providers are looking for deeper insights into the broader determinants of healthcare outcomes, particularly as they relate to patient experience. Quality is increasingly understood as a broad measure of a patient's journey from initial symptoms through post-treatment follow-up, and not just in terms of a discrete therapy or intervention.

Why Patient Experience Is More Critical Than Ever

One influential study defines patient experience as “the sum of all interactions, shaped by an organization’s culture, that influence patient perceptions across the continuum of care.” In this context, a literature review published in the Patient Experience Journal shows that myriad factors affect the patient experience, including:

• Organizational variables, such as the admissions and discharge processes, communication and a culture of respect.
• Outcome variables, related to factors such as patient safety, dignity, anxiety and engagement.
• Design variables, ranging from cleanliness to room privacy to pleasant artwork and access to the outdoors.

While this paper focuses chiefly on design-related variables, research clearly demonstrates that all of these factors are closely interrelated. Patient engagement, for example, is recognized as a prime contributor to overall satisfaction; a culture of open communication and proactive engagement helps reduce patient anxiety and increases confidence in healthcare providers. Critically, research shows that how crucial it is to understand patients’ expectations. In many cases, these expectations relate directly to interactions with physical space, which is precisely why the patient experience is understood using a more holistic, human-centered approach. Indeed, an extensive 2008 literature review of over 600 studies by Ulrich et al. demonstrated positive links between patient engagement and environmental factors including nature views, noise reduction, ease of wayfinding, and staff workstations that were easily visible from patient areas. A sense of control over the environment is also associated with higher satisfaction levels and the perception of a superior quality of experience.

Patient Perspectives on Healthcare Quality

Almost every healthcare organization recognizes the continuous improvement of patient experience as a valuable goal. The question is how to build more transparency into the nuanced factors that shape the overall patient experience — and how to translate these factors into actionable standards.

Traditionally, discussions of patient experience in healthcare have hinged on a single piece of evidence: survey data. Survey data provides high-level, quantitative insights that are useful for assessing the overall effectiveness of a healthcare organization. In many cases, however, an exclusive focus on satisfaction survey results can obscure the organization’s understanding of the specific qualitative factors that are actually driving these satisfaction outcomes. Knowing whether a patient ended up satisfied or dissatisfied provides little valuable information on the why of this outcome.

Limitations of Traditional Surveys in Assessing Patient Experiences

Understanding the holistic human experience of interacting with a healthcare organization is different from simply measuring patient satisfaction at a given moment in time. Patient experience is individual, personalized and incredibly difficult to measure using traditional surveys. The holistic patient experience extends beyond a specific clinical encounter in a given care setting, to the full continuum of healthcare experiences from the moment a patient begins setting an appointment.

Today, traditional approaches to patient satisfaction surveys are being challenged more than ever. As more granular metrics tied to patient outcomes and experience become the basis of healthcare reimbursement, healthcare organizations need to establish practices for continually evaluating the patient and family experience and prioritizing potential avenues for improvement.

What Are Human-Centered Experience Standards?

Human-centered experience standards refer to a process-oriented approach to instituting continuous improvement in the patient experience. In this context, patient experience is understood holistically, to encompass the full array of nuanced factors that go into shaping healthcare interactions.

These standards include specification standards for readily quantifiable patient experience factors such as room size, appropriate window treatments, requisite room furniture and surface finishes. Because these factors are more straightforward and quantifiable, most healthcare organizations have more robust existing practices for standardizing these aspects of the patient experience.

A holistic healthcare standard should seek to reach beyond these immediately quantifiable factors to capture the full array of qualitative factors shaping the patient experience (Figure 1). These human- centered standards include considerations such as nature views, noise reduction, ease of use and wayfinding.

Examples of Existing Standards and Their Impact

The purpose of human-centered standards is not just to reduce these considerations to specifications, such as sound level readings or additional sign requirements for wayfinding. Instead, these standards should be used to bring greater transparency to the patient experience and open novel avenues for improvement based upon staff and patient feedback. Natural light, for example, can be used to shape more intuitive wayfinding and decrease staff burnout. Another example of a human-centered standard is making patients feel welcome and reducing their sense of anxiety by making eye contact with each new visitor within 15 seconds of entering the facility. In this case, a relevant standard would be placing reception desks within 25 feet of all entry points, facing the door. A healthcare organization may also employ broader standards for helping patients escape the stress of diagnosis or care, such as positive distractions like music options or virtual reality, interactive artwork, access to daylight and views of nature. The list below illustrates how a number of patient experience goals can be directly related to concrete design solutions.

Experience Goal:

• Think about the comfort and value my support system brings to my care.
• Include my support system in my care plan.
• Don’t make me feel isolated or like I’ve been forgotten.
• See that others don’t overhear my private conversations, and I don’t hear theirs.
• Keep care areas dedicated to my medical care team.

Design Solution:

• Provide private rooms with social support zones and comfortable seating.
• Provide low-height counters at care team stations and areas for inclusive medical discussions.
• Design spaces that encourage interaction. Include visibility to care team stations.
• Implement white noise or soft music so conversations are kept private.
• Design circulation routes that allow offstage serviceable areas.

While this white paper focuses on these standards as they relate to built spaces, patient experience in these spaces is often closely interrelated with other operational areas, such as digital user experience, sign-in procedures and staff engagement. For example, patient experience will always be directly influenced by individual interactions with caregivers and other healthcare professionals, and staff experience should be evaluated as part of any holistic analysis of the patient experience. Research consistently shows a strong positive correlation between staff and patient satisfaction. Well-rested staff working in a positive environment that promotes accomplishing their shared goals with patients will always be an invaluable foundation for improved patient experience.

In turn, improved employee retention can help nurture a more experienced workforce with improved patient interaction skills. A standard centered around employees, for example, might seek to increase recruitment and retention through the provision of dedicated staff areas for rest, respite and de-stressing, such as lounges and dedicated staff-only dining areas.

Implementing Human-Centered Patient Experience Standards

Effective human-centered patient experience standards need to incorporate an incredible breadth of organizational perspectives, and it is important to gather insight from a variety of stakeholders to build a complete vision for an improved experience. Every healthcare organization is unique, and standards do not provide a one-size-fits-all solution. Rather, effective standards development should be rooted in an ongoing process of knowledge gathering from as many different sources as possible. Data from the following sources can be synthesized with traditional data sources like patient satisfaction standards in order to develop a complete picture of the patient experience.

• Dedicated working groups such as a Patient & Family Advisory Council, which help institutionalize the aggregation of feedback on patient experience and provide a dedicated forum that helps empower patients and promotes engagement.
• Focus groups (including both patients and staff) that incorporate as many different perspectives as possible, including patients, employees, providers, operations staff and facilities staff.
• Direct observation, including observers simply sitting in existing spaces and observing how people interact with the space. Are people moving purposefully in the space, or are they aimless and confused? Are visitors agitated or relaxed? Is the space designed to accommodate the desired audience?
• New technological solutions, like real-time experience rating tools, that open new possibilities for assessing patient experience and gathering patient feedback.

Key Challenges in Implementing Standards

While most healthcare organizations recognize the importance of improving patient experiences, going from ideation to execution can be a real challenge in the face of limited capital budgets, competing priorities and rising costs.

How, for example, can the chief financial officer be convinced that allocating precious square footage to an employee lounge with no revenue generation potential is a worthwhile investment? Particularly early in the implementation process for new standards, securing buy-in from key stakeholders may require generating robust estimates for the monetary benefits of high-priority investments in improved patient experience — in this example, perhaps through improved staff retention, recruitment, work attendance, and morale which studies can relate directly to patient outcomes and cost reduction.

Successful initial projects that demonstrate value through survey scores and Medicare reimbursement rates will help build a cultural recognition that proactive improvements to patient experience standards can make everyone’s lives easier, save money, create loyal patients and drive new efficiencies. An organization that systematically implements patient experience standards will always be less likely to make the same mistakes twice. Even a seemingly modest change, like specifying door hardware to replacing something that wears too quickly, can lead to significant cost savings over the long term, while contributing directly to a cleaner, more orderly space and saving hours of labor time. Over time, a culture of continuous improvement should become increasingly embedded in the organization, and less time and effort will be required to convince stakeholders of the need for change.

Ultimately, research has consistently shown that improved patient experience will serve both clinical and business goals, including improved patient outcomes, increased profitability and improved regulatory compliance through enhanced patient safety and a reduced risk of malpractice. Patients have proven that they will continue to seek the highest possible standard of care from alternative providers. One study found that U.S. hospitals that deliver a customer experience rated as superior achieve 50% higher average net margins compared to those rated average.

Leveraging Standards to Build a Culture of Continuous Improvement

Moving forward, insights gathered using the methods outlined above should be synthesized to build a cohesive vision for how the desired human-centered patient experience can be layered into organizational culture, branding and standards (Figure 2). From here, the immediate challenge shifts to design and implementation, but it is critical to not treat this initial knowledge-gathering work as a one-off exercise. Instead, the development of human-centered standards should be instituted as an iterative process founded on an institutional commitment to continuous improvement.

Regular post-occupancy walkthroughs are an instructive example of ongoing management practices that can help support continuous measurement, evaluation and improvement. For example, one year after a facility opening or renovation is the appropriate time to conduct a warranty walk with the relevant general contractor and architect. This practice is a great way to identify readily solvable issues that were missed in the first round of knowledge gathering, generating insights that the involved partners can incorporate on the next project.

In one example, a post-occupancy walkthrough noted that walls within weigh stations were beaten up, with virtually each one in need of paint despite only a year in use. In this case, the issue was addressed via new specifications that every weigh station must be surrounded with wall protection. This example shows how even a minor change can help create a better-maintained environment for patients, all while eliminating a recurrent maintenance issue to save time and money.

Maintenance requests also provide a valuable window into potential opportunities for improvement. If an issue continues to recur, this fact should inform the next round of improvement projects. Operational leaders are a great source of feedback on how humans are interacting with design. Alternatively, one can just look for improvised signage, a readily recognizable sign of a potential design issue.

Regularly collecting and disseminating these changes and insights is important for measuring their success before beginning another project, so that adjustments can be made. Over the long term, human-centered standards should work to nurture a true culture change in the organization. For example, hiring practices should be adapted to focus on candidates who are comfortable with change, proactive about seeking improvement and excited by innovation. Over time, staff should see the tangible evidence of their input reflected in concrete improvements to their working environment, a positive feedback cycle that helps generate buy-in.

Case Study: Patient Experience as the Foundation for a New Primary Care Model

One major health insurance system sought to implement an entirely new concierge primary care model. This case was a rare opportunity, and not every organization has the opportunity to start from scratch in designing a new patient experience. The fundamental takeaways from this engagement, however, are applicable to projects of any size, including both new facilities and remodels.

The project began with a focused research project designed to help understand what customers wanted from their health insurance plan. This initial research, drawing on behavioral studies, focus groups and other research, reached an interesting conclusion: People wanted a place to engage with their healthcare concerns, not just an insurance plan. Less than two years later, this research drove the creation of the health plan’s first care center, based on a design directly informed by customers’ feedback. For example:

• Customers wanted to complete requisite paperwork ahead of time. Procedures were adjusted to see that all paperwork was electronically available to patients in advance of visits. This change helped reduce waiting times, gave patients time to gather all the needed information and reduced stress upon arrival for their visit. Based on a series of dedicated design sprints, the system implemented strategic member experiences for pre-arrival, greeting and post-visit wraparound services like behavioral health services and health coaching.
• Patients wanted their healthcare provider to know them individually and anticipate their arrival. With paperwork completed ahead of time, front desks could be redesigned to focus less on gathering information and more on providing a welcoming experience. Front desks were designed as high-top, solid surfaces, easily approachable and located immediately by the front door. To focus this space on human interaction, these welcome desks would feature no phones or computer monitors. Any necessary sign-in procedures would be performed by staff via iPad.
• In exam rooms, local art and comfortable furniture gave rooms the feel of a home living room, with monitors that could provide education, and other visible equipment minimized.

The system defined hiring processes designed to emphasize empathy, part of a systematic effort to develop a culture built on a human-centered patient experience. These efforts extended to the brand itself, which shifted terminology to focus on care (employing care centers, care guides and care advocates) and to emphasize membership in the plan as something underpinned by a real sense of trust, support and belonging. Patients were referred to as members.

Moving forward, improvement would be measured using care team surveys, member surveys (with items specifically tailored to reflect the type of visit) and patient input from a real-time experience rating tool. After one year, the leadership team conducted a three-day listening tour to gather input and create a detailed action plan for continuous improvement in the program’s second year. During new member orientation, members would meet with a care guide at the conclusion of the visit, an opportunity to collect more detailed qualitative feedback on the experience. Open houses for prospective members were also leveraged as an opportunity to collect further feedback on the desired patient experience. As this feedback was received, the design and facilities team, operational and clinical leadership, and original research partner came together to utilize these new insights to make changes to the overall layout and offerings at future care centers.

Conclusion: The Future of Healthcare Standards

Nurturing an organizational commitment to developing and executing new human-centered standards is a complex challenge. While the precise path forward for each healthcare organization will be different, moving beyond surveys and toward a more holistic concept of the patient experience is a reliable first step toward a true culture of continuous improvement.

As healthcare leaders and policymakers continue to look for more innovative payment models and granular quality metrics, the imperative for standardized approaches for improving patient experience will only grow. As we have explored throughout this paper, moving proactively to identify priorities for improvement will put any healthcare organization on a path to better patient outcomes, greater patient loyalty, more efficient operations, better talent retention and, ultimately, better financial performance.