When arranging a reception area, which type of chairs would best accommodate elderly patients?

Semin Hear. 2016 Nov; 37(4): 316–324.

Guest Editor, Gyl Kasewurm, Au.D.

Abstract

The concept of the patient experience as it relates to patient satisfaction is a complex dynamic. It is a dynamic that is becoming increasingly more important as patients are faced with multiple choices for their hearing and balance care. As reimbursement and performance policies have become more normative within health care, patient satisfaction has become a metric to measure quality. Patient satisfaction is no longer contained to just the interaction with the audiologist. It extends to the entire experience—the staff, the service, the product, and other factors. Many practices fail to capitalize on one of the primary components of the patient experience—office design. This article discusses the role of evidence-based design in facility planning as it relates to patient satisfaction. It will illustrate how design principles and ideal attributes may be used to send conscious and subconscious cues that will motivate staff, facilitate patient-centered care, and ultimately increase patient satisfaction.

Keywords: Evidence-based design, practice-based evidence, interpersonal sensitivity, egalitarian presence, shared decision-making

Learning Outcomes: As a result of this activity, the participant will be able to (1) identify the differences between evidence-based design and practice-based evidence as they apply to design decisions; (2) identify design components that facilitate mutual participation through interpersonal sensitivity, egalitarian presence, and shared decision-making.

Growing a practice can be expensive. The estimated cost of acquiring a single new patient is $250 to $300.1 It is also 6 to 7 times more expensive to acquire a new patient than it is to keep a current one.2 Retaining a patient can be challenging in the face of price war advertising, big box sales, and managed care contracts. Practitioners manage their databases, market through social media, and advertise all in an attempt to connect with the consumer. But connecting is only the first step in managing the patient experience. More importantly, the practitioner must understand what their patients want, need, and expect.

The Affordable Care Act, social media, and other changes in the health care system have transformed the way patients expect services to be delivered and performed.3 Health care has become a patient-centric, consumer-driven industry in which the provider must learn how to meet patient expectations and provide the right experiences that engage the consumer and nurture a lasting relationship. One of the major influences in the patient experience is the physical component of a practice environment.4 5

A large and growing body of evidence supports the belief that the physical environment of a health care practice impacts stress, safety, effectiveness, quality of care, trust, and ultimately the level of patient satisfaction with a health care provider.5 6 7 Though anecdotally many audiologists and health care providers have been aware of this impact, quantifiable data has only begun to emerge. Evidence-based design (EBD) is a term being used to describe this growing field of study.4

EBD is the process of basing decisions about the physical environment on credible research to achieve the best possible outcomes. EBD studies examine how the physical environment of health care spaces can influence perception and outcomes. Many hospitals, health centers, and private health care practices are adopting EBD when considering new construction, expansion, and remodeling.4 8

There are few if any audiology specific EBD studies published. However, parallels can be drawn between audiology practices and the EBD data obtained from other health care settings. Office design that facilitates easy access, privacy, family inclusion, and comfort, whether the practice is situated in a hospital, university, physician office, or private audiology practice, are universally going to promote lower stress, increase compliance with treatment plans, and improve staff accuracy and mood, ultimately resulting in higher patient satisfaction, patient referrals, and patient retention.3 6

It would be ideal if audiology practices could provide EBD studies to help quantify the benefits of design considerations but it can be difficult to obtain a sufficient sample size and adhere to the rigor of scientific study. In private practice, time is critical and decisions about design application need to be made in relatively short periods. A more immediate, less rigorous alternative is to consider practice-based evidence (PBE).9 Design considerations using PBE are project specific and utilize data from patients and staff, collected through the use of observation, survey, or interview. PBD may take many forms but has three key criteria10:

1. The research is done within the facility or practice in which the remodel/redecorating/expansion will be done. The findings are project specific and may cover many small areas of investigation (i.e., placement of furniture, lighting, addition of a coffee station).

2. The time frame for collecting evidence is short, taking a few days or a week. The research is much less rigorous than academic research but the primary purpose is to generate empirical evidence as opposed to relying on impressions or preconceptions (e.g., gather data about where people sit or which seat style they choose—do they prefer seating close to the window, in a corner, on a chair, or bench seat?).

3. The means of data collection can vary using interviews, surveys, or observations. There will be fewer data points than academic research but the information can generate insights based on a more structured assessment than just assuming something works because no one has complained or it seems like a good idea.

Design decisions made using PBE also may reflect regional attitudes and preferences that will have impact on the patient experience and ultimately, patient satisfaction.11

The patient experience begins with the very first contact a patient has with a practice. It may be a brief look at a direct mail piece or driving by the office. Some experiences will be more substantial like viewing a television advertisement or talking with an existing patient. No matter how brief or substantial the exposure, that patient has begun to develop an opinion about their patient experience. Business consultant and author of Clued In, Louis Carbone identifies the development of a consistent, positive patient experience as the best opportunity for business growth. The patient experience is made up of sensory building blocks or clues that are being delivered to the patients, consciously and unconsciously. Marketing research and scientific studies have shown that up to 95% of what influences a consumer's conscious choice is the unconscious interpretation of these clues.12 The office environment is the primary location of these important clues. Design choices matter. Approximately 24 to 35% of a patient's overall satisfaction with a health care experience is influenced by the design and decor of the facility.13 14 As Carbone described, “The tangible attributes of a product or service have far less influence on consumer preferences than the subconscious sensory and emotional elements derived from the total experience.”12

Being a great audiologist no longer guarantees customer loyalty or patient referrals. A 2011 survey found that 3 in 5 Americans (60%) would try a new brand or company to have a better experience.15 It is the great overall experience that will lead to patient retention and growth.

Researcher Sergei Kochkin explains that simply satisfying patient needs is not enough. The patient experience must exceed expectations to gain patient loyalty and their referrals. Providing an exceptional experience transforms the satisfied customer into a highly satisfied patient. These patients become practice advocates or disciples, willing to refer friends, family, and acquaintances by sharing their positive experience, likely through social media.16

Though not the only factor in developing a disciple, the office can be a valuable tool to that end. Factors like limited parking, old furnishings, poor lighting, awkward patient flow, or barriers will take a heavy toll on patient satisfaction. Purposeful and consistent clues supplied by your design and décor may take the patient from being merely satisfied to being a practice advocate.

Design Considerations

Design considerations start in the parking lot. Having sufficient parking, easy access, and well-marked navigation is important to setting the tone for the patient experience. Well-maintained landscaping and storefront design provide clues about the conscientious, responsible practitioner within. Make design/landscaping choices that meet the level of maintenance available.

Signage

Sign design should make it easy for patients to identify services, locate the practice, and increase visibility within the community. Signage should be easily legible from the street. Using high-contrast colors like black or red on white or gold provides good visibility from a distance. Lighted signage stating the primary purpose of your company also will help increase visibility and awareness of services available to the community. Because the patient experience often begins with advertising, it is helpful to capitalize on good signage by using photographs of the practice exterior in all advertising and marketing media. Signage recognition reinforces the familiarity and presence in the community resulting in reduced patient stress and increased trust. If there is no direct street access to the practice or if the practice is located within a multioffice suite, be sure to have easy-to-read identifiers such as suite numbers and interior signage. Make sure routes through hallways are clearly marked. Patients need to feel that they are in control. They will not have a highly satisfied experience if they cannot find the practice, enter through the wrong door or need to ask for directions.6

Front Desk And Waiting Area

Making a good first impression is imperative to setting the tone for the highly satisfied patient experience. Upon opening the practice door, a patient will need to feel welcomed, comfortable, and in control.17 Do not underestimate the power of the word welcome. Design the staff reception space with easy access to office equipment, checkout/payment areas, and patient information/files without having to leave the area. These considerations allow for the staff to be always present and ready to welcome or assist the patients.6

Provide an area of patient-controlled space between the entry door and the reception desk where the patient can decide to move forward, take a seat, hang up a coat, and so on. This space allows the patient to feel they are going to have some control over their experience.18 Design the reception area to capitalize on a feeling of inclusion. The reception desk should feel like it is part of the patient waiting area. Reduce barriers like glass reception windows, blinds, or small openings. Well-placed, highly visible reception areas provide a welcoming face and imply partnership to the patient, relieving stress and providing reassurance that they have chosen the right provider.19 Make sure the reception is staffed during business hours.

A highly satisfying patient experience centers on the fundamental human need for control and competency.5 Decor and design provide the patient with control moments like where to sit, whether to read a magazine, or whether to have a beverage. Support a patient's sense of competency by making it easy to navigate the practice, use the coffee station, or locate restrooms without asking for directions or assistance. Incorporate signage and instruction with frames, custom art, or displayed in a way that supports the theme or vibe of the office.

The waiting area should provide opportunities for the patient to learn about the practice, practitioner, and staff. Color, lighting, and art set the mood for the patient experience, for example, a sleek design with florescent lighting and monochromatic color scheme may suggest high energy and modern technology where earth tones, incandescent lighting, and natural stone may imply warmth and compassion.20 Additional considerations include:

• Use geographically inspired themes to promote familiarity.

• Incorporate colors from your logo or meaningful colors represented in the community like a sports team or college.

• Use decor and design that support your message: modern, fresh, unique, warm, comfortable.

• Lighting may be used to reinforce a theme or mood. Incandescent lighting can provide a warm hospitable feel whereas bright fluorescent ceiling lights can evoke feelings of movement and high energy.

• Incorporate nature via windows, plants, water feature, and so on into your decor. Views of nature can reduce stress and provide a sense of well-being.

Another point of patient control that can be addressed by design is personal space. Personal space is a transportable invisible boundary around the patient and is one factor that determines how comfortable a person is within an area like a waiting room. E.T. Hall, author of The Hidden Dimension, defines four zones of interpersonal distance 0 to 1.5 feet is intimate space, 1.5 to 4 feet is personal space, 4 to 12 feet is social distance, and 12 feet and beyond is public space (there are cultural differences that may need to be considered). These zones may serve as guidelines for furniture placement in areas of patient interaction.21

Furniture is an important tool for defining proxemics zones. Seating not only gives the patient a place to relax, it also can help define the patient controlled space, giving the patient a sense of ownership. Utilizing chairs that have arms establishes spatial boundaries as well as helping the patient get up. The arms define where one patient's space ends and another begins. Avoid chairs that have shared arms as this area can become contestable, causing patient stress. If the seating area is less than 8 feet apart, staggered seats allow patients to easily avoid eye contact with the person sitting across the aisle, protecting the area of controlled space. Having sufficient seating provides patients with choices.22

Other considerations include:

• Seating materials should be durable, moisture resistant, and cleanable.23

• A variety of comfortable seating options should be available.

• Chairs should be in good repair and regularly disinfected.

• Seating should be arranged in small conversational groupings especially if multiple family members are likely to be in attendance during appointments.

• Small chairs and tables should be used in pediatric practices.

• Be creative—example: a practice that uses reclining massage chairs because they cater to industrial workers who are on their feet all day, or the practice that uses padded bleacher seats inspired by a local professional baseball team.

Consider incorporating a coffee or water bar into the decor. Offering food or beverages creates a subconscious attachment between practice and patient, increasing compliance with treatment recommendations and patient loyalty.24

Make sure to design areas where patients, guests, and staff can hang up coats or umbrellas. Have hooks in all shared rooms that allow for patients to hang up personal belongings within their sight. This accomplishes the feeling of security for the patient and decreases the likelihood of tripping or falling over misplaced personal items.

Television And Music

Medical researchers have found that “the waiting room might best function not as an area where a captive audience can be bombarded with health promotion messages, but rather as a place for relaxation before consulting a health professional.”25 Television was found to add stress to the patient experience, especially when patients are unable to control volume or programming.

Music is one design element that may be used to accomplish several objectives. It can serve to mask private conversations, engage patients who may be waiting, and it also can boost staff morale. Researchers have found that relaxing music promotes the release of endorphins and immunoglobulin, making patients more receptive to health advice in the consultation.25 Many listeners describe relaxing musical elements as a slow and stable tempo, absence of percussive and accented rhythms, low volume level and soft dynamics, connected melodies, gentle timbre, and simple harmonic or chord progressions.26 Music is, however, very subjective. What one patient may enjoy another may find bothersome. If music is used in the office keep volumes low and screen musical selections to ensure there is no offensive language.

Patient Treatment Rooms

One of the most stressful moments of a patient encounter is the moment a patient is called into an evaluation room. Stress is the result of unfamiliarity with the care provider, not knowing what will happen next, and the relinquishment of control.4 When designing or redecorating a waiting area, allow for an open space between the professional's entry area and patient seating. Patients should not be approached in this area unless invited. As the patient moves through the open space it will provide the patient time to consciously and subconsciously commit to the evaluation process and to prepare themselves to engage in mutual participation with their hearing/balance needs.23 Health researchers define mutual participation in three dimensions: interpersonal sensitivity, egalitarian presence, and shared decision-making. Each of these principles is essential for transforming the patient experience into a highly satisfying encounter.

Interpersonal sensitivity addresses the understanding that the provider has about the patient realizing that compliance for any treatment recommendations are going to be affected by a combination of factors including biological factors like severity of loss, psychological factors like personality or mood, and social factors like relationships or economic status. Room decor and design must facilitate an opportunity for the provider and patient to get to know each other. Using upholstered chairs around a low table invites comfort, safety, and conversation. The seating should allow everyone to sit at the same level in conversational proximity. This posture demonstrates to the patient that they have the professional's full attention.27 The lack of barriers between patient, family, and professional shows nonjudgmental acceptance, making it easier for patients and family to share their concerns fears and desires.

Interpersonal sensitivity also needs to work in the reverse. Room decor should allow the patient an opportunity to recognize the personal side of the provider through clues placed to demonstrate values, experiences, and expertise.18 Photographs, diplomas, licenses, plaques of appreciation, and community service are important visual indicators. Using four to seven indicators is sufficient to achieve the desired impression; too few may imply inexperience, too many may be intimidating.18 These visual clues help the patient form a sense of familiarity and history. Once a patient feels they know their professional it becomes easier to have open conversation. It also increases the likelihood of patient compliance with recommendations.27

Orderliness is also a valued clue. For this reason the decor and design of the office space should provide sufficient storage to reduce clutter. Research has shown that people make inferences about a room's occupant from the display of artifacts in the room. People associate clean and organized spaces with individuals who are highly conscientious. A messy desk and worn-out furniture and dusty shelves can communicate that the practitioner does not pay attention to details and ultimately to their patients.28 Patients subconsciously associate a cluttered room as a sign of poorer skills, less professionalism, and substandard care.20

Egalitarian presence means that the furniture, technology, and physical placement in the room needs to be designed in a way that encourages participation from all players. Many patients will be accompanied by a spouse, parent, child, friend, or significant other. Accommodating additional people so all can participate can be challenging. Using moveable furniture and versatile storage may provide quick and easy room reconfiguration. Incorporation of hooks and storage space into the decor keeps coats, purses, and personal items out of the way, improving safety, ease of access, and unencumbered movement.

Designing a floor plan with larger rooms also can provide better flexibility without having to move the patient from room to room. This can be especially important in cases where mobility is an issue or there are several people in accompaniment. The use of sliding screens or panels can further define room size. Screens can be opened to create a smaller, cozier environment when there are only a couple of participants or closed to allow more space when there are multiple participants so no one is relegated to a corner chair. Studies have found that self-disclosure was more forthcoming and extensive in a warm, intimate room.19 Smaller spaces also are perceived as more private, which increases the feeling of trust between patient and provider.

The arrangement of furniture can be used to accomplish other fitting, counseling, and patient educational goals. Having moveable furniture allows the practitioner to change the clues that will enhance patient satisfaction with their experience.

• Chairs perpendicular implies teamwork and support.

• Chairs side by side supports education and instruction.

• Chairs face-to-face shows expertise and can be used to gain compliance.

With the use of electronic records and computers, it can sometimes be difficult to maintain eye contact with a patient. Allowing for computer screens to be off to the side with the keyboard flat on a desk keeps the line of sight open. For conversation, everyone should be seated at equal height. This implies that all thoughts, opinions, and concerns can be shared and that everyone present is equal. In a patient-centric environment, family members also need to have an opportunity to offer insight, observations, and support.23

Critical to shared decision-making is the opportunity to exchange information. To promote transparency, computer screens should be placed so patient and family can review records, teach, and engage patients in discussion. Sharing a computer screen accomplishes several goals:

• Promotes openness between clinician and patient

• Encourages eye contact with the patient and family

• Increases accuracy and patients or family can interject if the information is incorrect or needs further explanation

• Includes the patient and family in the evaluation (re)habilitation process by sharing goals, visual reinforcement, and/or educational information.29

Ambient Temperature

A building's heating and cooling system underlies the comfort of patients, as does a good filtration system to remove odors and irritants. Older adults are often colder than younger adults.30 Comfortable room temperatures tend to be higher the older the patient. Designing rooms with variable vents will allow for room-specific climate control without the need for room specific thermostats. Avoid placing furniture directly below/beside vents.

Privacy

Privacy is of utmost importance throughout the practice. Lack of privacy is not only a potential HIPAA (Health Insurance Portability and Accountability Act) violation; it is also a factor that can change patient behavior. The use of acoustic barriers, for example, floor to ceiling walls, acoustic tiles, white noise generators, solid doors, and other acoustic insulation, increases a patient's sense of security when sharing personal information and feelings. The floor plan should allow for acoustically secure areas for staff to discuss patient information or for patients to share sensitive information with support staff, such as financial information. When a patient feels secure they will tend to be more honest and forthcoming with personal information.6

Noise

Excessive noise can be a distraction to patients, guests, and staff.31 For first-time hearing aid users, noise can be more than an annoyance. Design elements can be used to muffle noises without changing the floor plan. Considerations including acoustic tiles, playing calming music, or use of a water feature. When children are frequently in attendance, designate play areas by using acoustic tiles, walls, or acrylic panels to help confine and contain noise.

Effective Patient Flow

With a clear understanding of how patients move through a practice, a floor plan can be designed with a sequential flow that reduces bottlenecks, increases privacy, and expedites more efficient staff movement. Office reconstruction is not always necessary to accomplish a change in patient flow. Often a rearrangement of furniture or an addition of privacy screens completes the transformation. Simple design changes can alleviate patient stress and provide improved staff function and improve the patient experience.

Light And Nature

Introducing more natural light in a waiting or work area can improve the mood of patients and staff. Studies have found that natural light and a connection with nature (window) can lower blood pressure and stress.32 Windows and skylights introduce more natural light, but shades may be needed to prevent sunlight shining in people's eyes or to control heat from the sun. The use of plants, flowers, and artwork can provide a connection to nature. Covered fish tanks also can provide a soothing distraction but they do require regular maintenance. Lighting also can be used to create a mood or reflect a level of activity. Staff areas should have good lighting to help decrease eye strain and errors. Patient areas should have lighting appropriate for the activity. This may mean dim lighting for test booths to promote relaxation and concentration but bright lighting for areas used for patient instruction to increase energy level and provide better visibility.

Color

Though there are many anecdotal reports of color affecting mood, there is no evidence-based research that proves one color over another results in a particular behavior. Color is an easy and inexpensive way to refresh an environment. Studies have shown that simple changes made to a work environment (such as painting) has a significant impact on the moral of employees, ultimately improving patient interaction and reducing errors.33

Color also may be used to identify separate areas of activity, like using a brighter hue in a room area where children may play. Identify the primary purpose for each space and consider who will be in the space most often. If space is an issue, using a single paint color throughout the facility can give the feeling of a larger area. Neutral colors like taupe or gray will have the most universal appeal. Use accent pieces or artwork to incorporate color for self-expression or interest. Having staff input on color choices also may help with their mood or sense of ownership. Color may be used to reinforce a theme, mood, or message. Earth tones are often equated with warmth, greys with technology, white with cleanliness. Though the color of the walls may not cause direct behavioral changes, color can be a tool in defining the overall patient experience.3 Use color to help patients and accompanying guests easily identify different areas of room use. A colorful corner can denote a play area for accompanying children. The use of a darker hue on a wall or change in carpet color or pattern within a single room can create the feel of moving to another room allowing for a change in mood, task, or level of engagement.

Office design and decor has a considerable impact on employees. Staff morale, accuracy, and efficiency increases as a result of minor design changes. Mistakes stem from human error caused by multitasking, interruptions, distractions, and changes in established routine. Design considerations can help reduce errors. For example, adequate fresh air can reduce fatigue, diminished noise can increase concentration, isolated work areas can decrease distraction, and appropriate lighting can shrink errors caused by misreading data. Using adjustable chairs, desks, and computer platforms can cut irritation and fatigue by increasing comfort and functionality. Making decor changes like painting a hallway, hanging new artwork, or designing a more efficient workspace results in the halo effect experienced by the patients.6 Happy, effective employees have great influence on patient loyalty and overall perception of quality of care. It is important to periodically refresh and renew the decor to keep employees safe, engaged, and responsive to patient needs. A patient's perception of staff encounters is one of the most important components of a highly satisfied rating.13 27

Investing in the physical design and decor of a practice yields significant benefits to office functionality, staff performance, and overall patient satisfaction. Through the use of carefully planned and placed clues, practitioners can influence patient compliance and outcomes, turning satisfied patients into disciples.

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