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J Ambulatory Care ManageVol. 31, No. 2, pp. 128–141Copyright c© 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

The Ecology of the Patient VisitPhysical Attractiveness, WaitingTimes, and Perceived Quality of Care

Franklin Becker, PhD; Stephanie Douglass, MS

Abstract: This study examined the relationship between the attractiveness of the physical environ-ment of healthcare facilities and patient perceptions of quality, service, and waiting time throughsystematic observations and patient satisfaction surveys at 7 outpatient practices at Weill CornellMedical Center. Findings indicate positive correlations between more attractive environments andhigher levels of perceived quality, satisfaction, staff interaction, and reduction of patient anxiety.The comparison of actual observed time and patients’ perception of time showed that patients tendto overestimate shorter waiting times and underestimate longer waiting times in both the waitingarea and the examination room. Further examinations of the way outpatient-practice environmentsimpact patient and staff perceptions and how those perceptions impact behavior and medical out-comes are suggested. Key words: ambulatory, design, facilities, quality, patient perceptions,waiting times

NEW CHALLENGES ranging from advanc-ing technology to increasing costs are

changing the face of healthcare and forcinghealthcare organizations to shift their focusand change the way they operate. One majorchange has been in the ratio of inpatient tooutpatient visits. Since the 1950s, the yearlytotal of outpatient procedures has risen. In1975, there were 190 million outpatient visits.In 1995, there were 425 million, and in 2004,575 million (American Hospital Association,2006; Pressler, 1993). As more ambulatory fa-cilities are constructed to meet the increasingdemand of outpatient procedures, healthcareorganizations have begun to realize the impor-tance of attracting people to their facility.

Many of these people are older. The shift-ing demographics of the patient populationare having, and will continue to have, a majorimpact on the way that healthcare is deliv-ered as well as consumed. Currently, 27% of

From the Department Design & EnvironmentalAnalysis, College of Human Ecology, CornellUniversity, Ithaca, NY.

Corresponding author: Franklin Becker, PhD, Depart-ment Design & Environmental Analysis, College of Hu-man Ecology, Cornell University, Ithaca, NY 14853.

Americans (approximately 80 million people)are older than 50. In 20 years, approximately35% of the US population will be older than50 (Department of Health & Human Services,2006; Pressler, 1993). The baby boom gen-eration utilizes healthcare in different waysthan previous generations. This “prosumersociety” (Carpman et al., 1986) has higherservice expectations in all areas of their lives,including healthcare. As a result of thesedevelopments, healthcare organizations arefinding themselves under more competitivepressure from emerging “specialty” practicesthat have surfaced as a result of increasedpatient demand (Iglehart, 2005). Hospitalsand healthcare practices that previouslycontrolled their localized market share arenow facing competition from new hospitalsand practices, thus forcing them to reevaluatetheir own practice to retain a competitiveadvantage (Cuellar & Gertler, 2005).

PATIENT-CENTERED CARE

Over the last 20 years, a major focus ofthe rethinking of healthcare systems has beenon “patient-centered care” (Carpman et al.,1986; Malkin, 1992; Marberry, 2006), that is,

128

The Ecology of the Patient Visit 129

shifting the focus of healthcare to the needsof the patient, including using design to createmore patient-friendly facilities. In 2001, the In-stitute of Medicine included patient-centeredcare as 1 of 6 specific aims for improvementsthat are needed for healthcare to bridge thequality chasm that exists in today’s health-care system, along with safety, effectiveness,timeliness, efficiency, and equity (Institute ofMedicine, 2001).

The physical environment of

healthcare facilities

In response to changes in medical prac-tice and consumer expectations, in 2004 theUnited States spent more than $16 billion forhospital construction (Babwin, 2002; Ulrichet al., 2004). In 2006, healthcare constructionprojects worth more than $39 billion brokeground; the total projected costs of health-care facilities in the design phase in 2006 wasalmost $75 billion (Romano, 2006). A signif-icant proportion of this construction is forambulatory facilities. This marks a major shiftin focus from acute inpatient hospital careto an increasing range of outpatient services(Nesmith, 1995). With the shift to increasedoutpatient and ambulatory practices, thetypes of patient-outcome measures affectedby the facility design have also shifted.

Measures such as the average length of stay(in days), which make sense when the fo-cus is on inpatient care, make little sense inthe context of outpatient services. In ambula-tory facilities, time measured in minutes andhours becomes more relevant; so, too, doesthe consideration of the patient’s perceptionsof quality and satisfaction. Stern et al., (2003)argue that as healthcare organizations striveto satisfy their customers in a competitivemarketplace more attention is paid to howpatients perceive their physical surroundingsand how that experience affects their view ofthe healthcare they receive.

Quality of care and the

physical environment

Arneil and Devlin (2002) found that thedesign of outpatient waiting-room environ-ments influenced patients’ perceived quality

of care. More attractive waiting areas wereassociated with higher perceived quality ofcare. While this is one of the few studies tohave looked at the design of waiting roomson patients’ perceptions of care, the subjectswere not actually patients or physically in theenvironments themselves. Instead, subjectsused photographic images of the waiting-room environment to make their judgments.The study reported here seeks to test whetherthe relationship between physical attractive-ness of ambulatory-waiting environments andperceived quality of care holds up when ac-tual patients rate their quality of care in theambulatory waiting areas where they are be-ing treated.

Staff-patient interaction

While Arneil and Devlin found a relation-ship between physical attractiveness and per-ceived quality of care, Powers and Bendall-Lyon (2003) showed that patients’ evalua-tion of their overall healthcare experienceincluded interpersonal relations and interac-tions with staff, including their responsive-ness, courtesy, competence, and communica-tion. The performance and attitude of health-care staff can, in turn, be influenced by thephysical environment in which they work(Bitner, 1992; Davis, 1984). Becker and Poe(1980) found positive effects on the moodand morale of medical staff after several smalldesign modifications, such as repainting hall-ways, adding wall murals, and rearranging fur-niture, were made to their workspaces. A1956 study by Maslow and Mintz found thatsubjects perceived people more positively inbeautiful rooms than in ugly rooms (Maslow& Mintz, 1956). As Arneil and Devlin note,“many aspects of the perceived quality of carethat seem to be observable by the patientare not only positive interactions between thestaff and patient, but between the patient andenvironment as well” (Arneil & Devlin, 2002,p. 346).

Waiting times

A key factor that consistently emerges in pa-tient satisfaction studies is waiting times, both

130 JOURNAL OF AMBULATORY CARE MANAGEMENT/APRIL–JUNE 2008

in the registration process and to see a physi-cian (Press Ganey Associates, 2005). Usingpatient self-reported or staff-recorded wait-ing times, Miceli and Wolosin (2004) foundthat longer waiting times were negativelycorrelated with overall satisfaction. However,Miceli and Wolosin found that good commu-nication and a strong relationship betweenpatient and caregiver reduced these negativeeffects.

The most frustrating element of waiting canbe that there is generally no control over howlong the wait will be for a particular service.When in the overall visit waiting occurs alsoaffects patient satisfaction with the overallvisit. Waiting in a surgical unit has been cate-gorized into 3 separate phases: preprocess; in-process; and postprocess (Dube-Rioux et al.,1989). In the context of an ambulatory wait-ing room, preprocess is from the time of ar-rival to when the patient is taken back intothe examination area. Inprocess is the time be-tween entering and leaving the examinationarea. Postprocess is the remaining time it takesafter leaving the examination area for the pa-tient to complete all necessary paperwork andexit the facility.

Studies have shown that perceived and ac-tual waiting times also differ. In an extensivestudy of the influence of waiting on the per-ception of service quality in nuclear medicine,De Man et al. (2005) found that perceived to-tal waiting time was significantly lower thanthe objective waiting time, the perceived pre-process waiting time was significantly lowerthan the actual waiting time, and the per-ceived waiting time inprocess was higher thanthe actual time. Providing information aboutthe reasons for delay significantly reduced thedifference between the perceived time and ac-tual time.

Additional research has examined the rela-tionship between the perceived waiting timeand actual waiting time, how patients spendtheir time waiting, and service satisfaction. Ina study of an urgent care department, Dan-sky and Miles (1997) found that total timespent waiting for the clinician was the mostsignificant predictor of patient satisfaction. In-forming patients how long their wait would

be and being occupied during the wait werealso significant predictors of patient satisfac-tion. On average, patients spent 55 minutesin the waiting area before entering the treat-ment room, 17 minutes in the treatment roombefore a clinician entered, and 107 minutesoverall in the facility (Dansky & Miles, 1997).The longest waiting time was the total timespent waiting to see the clinician. This timesignificantly predicted satisfaction with clini-cians, the urgent care department, and overallsatisfaction.

ENVIRONMENTAL DISTRACTIONS

Few people look forward to waiting. De-pending on the nature and circumstances ofthe wait, the 3 phases of waiting (preprocess,inprocess, and postprocess) can result in2 basic psychological and physiological re-sponses: uncertainty, including annoyance, ir-ritability, and stress; and anger (Taylor, 1994).To reduce these responses, health facilitiestypically provide some form of distraction,most often television and/or magazines, in thewaiting space. Less often, distractions includethings such as indoor and outdoor views,patient-education resources, and refresh-ments. Such distractions, as well as givingpeople a choice of what they can do whenthey wait, have been shown to help reducestress and anxiety (Hosking & Haggard, 1999).

Despite the fact that waiting is a funda-mental fact of hospital visits, and that boththe length and experience of waiting can in-fluence patients’ and visitors’ perceived qual-ity of care, little research has examined howthe physical attractiveness of the settings inwhich waiting occurs influences perceivedwaiting times. The research carried out sofar has involved nonpatients and photographs(Arneil & Devlin, 2002) rather than actual pa-tients in the healthcare setting, and virtuallyall of the research on patient-centered care todate has focused on inpatient rather than out-patient facilities and services, although out-patient visits have increased enormously overthe past 2 decades. This study examined therelationships between the attractiveness ofthe physical setting and actual and perceived


waiting times, quality of care, anxiety, andstaff-patient interaction for patients in an out-patient facility.

METHODS

Research design and site selection

The target research sites were 6 clinical out-patient practices located in 6 facilities withinthe Weill Cornell Medical Center/New York-Presbyterian Hospital in New York City. Thefacilities varied significantly in physical attrac-tiveness overall, as well as within each of the 3types of medical practices examined: gynecol-ogy, dermatology, and gastroenterology. The3 less physically attractive practices were se-lected because of existing plans to move thosepractices into a new ambulatory care build-ing currently under construction by Weill Cor-nell. This created the potential for future re-search comparing patient and staff experi-ence between the new and existing facilities.Separate locations within the same healthcaresystem were chosen in an attempt to holdthe differences in staff quality, patient popu-lations, and organizational culture constant asmuch as possible in any large, complex medi-cal system.

Site descriptions

All practices are part of the Weill Cor-nell Medical College, New York Presbyte-rian Hospital system. Three of the practices,the Jay Monahan Center for GastrointestinalHealth and 2 practices within the Iris CantorWomen’s Health Center, were located in inde-pendent facilities within a few blocks of themain hospital complex, where the remaining3 practices were located.

Jay Monahan Center forGastrointestinal Health

The Jay Monahan Center for Gastrointesti-nal Health opened in 2004 and was the newestof the practices studied. Its design was in-tended to create a “spa aesthetic.” The prac-tice contains colorful contemporary furnish-ings and artwork and uses many sustainablefinishes and materials.

Iris Cantor Women’s Health Center

The Iris Cantor Center for Women’s Healthopened in 2002. The 10th-floor gastroenterol-ogy and dermatology practices and the 11th-floor gynecology practice had similar physicalenvironments, which included pastel colors,artwork by contemporary female artists, andmodern furniture.

The remaining 3 practices included in thestudy were located in the Weill Cornell Med-ical College, New York Presbyterian Hospitalcomplex, built in 1932.

J130 gynecology practice

This practice’s decor was characterizedby dark woods, classical furniture, andresidential-style ambient lighting.

Gastroenterology practice

This practice’s decor was characterized byneutral-colored walls, brightly colored syn-thetic furnishings, and bright lighting.

Dermatology practice

This practice’s design was characterized byneutral cream-colored walls, furnishings withsynthetic materials, and minimal decoration.

Physical environment ranking

Rankings of the physical attractiveness ofthe 6 facilities were completed by 6 CornellUniversity graduate students in non–design-related majors. The panel compared all ofthe practices on the basis of multiple pho-tographic images with no knowledge of thetype of practice, staff, or hospital affiliation.Each student was shown 4 photos of each ofthe 6 locations. Photos showed the waitingroom, examination room, and hallway of eachpractice. Panel members were asked to rankthe environments from most attractive to leastattractive. The results of their rankings werethen assigned a number value of 1 through6, with 6 being the most attractive environ-ment and 1 being the least attractive. Resultsof all the subjects were then combined to cre-ate an environmental attractiveness score foreach location. The theoretical maximum andminimum were 36 and 6, respectively, withthe higher number reflecting a more attractive


environment. Actual rankings ranged from 34to 9, with a high level of interrater reliability(Kendall’s W = 0.676).

Data collection

Multimethod data collection included sys-tematic observations and patient surveys. Ob-servations occurred over a 13-week period.Over the duration of the study, 787 patientswere observed across all practices in morethan 370 hours of data collection. Of the to-tal of 787 patients observed across all 7 prac-tices, 70% were between the ages of 25 and 50years, 80% were women, and 77% came alone.During the same period, 205 patient surveyswere collected from the 7 practices.

Systematic observation procedure

The amount of time spent waiting and therange of activities patients engaged in whilewaiting were recorded Monday through Fri-day, observing both morning and afternoonsessions. Observations were conducted by 2research assistants at a time, both of whomhad synchronized watches and data collectionsheets. One observer was located in the prac-tice waiting area to observe the time at whichpatients entered the practice, the registrationprocess, the activities engaged in while wait-ing, and the time until called back into theexamination room by a staff member. Thisobserver also noted demographic informa-tion including the patient’s age, gender, andwhether the patient had someone accompa-nying him or her on the visit. Intercoder re-liability for these demographic variables wasmore than 90%.

The second research assistant was locatedin the examination-room hallway, where shewas able to see the doorways of all examina-tion rooms. She observed patients from thetime they were brought in from the waitingarea by a staff member till they left the ex-amination room. The times at which the pa-tient entered the examination room, a nurseor medical assistant entered and left the ex-amination room, the doctor entered and leftthe examination room, and finally the patientleft the examination room were recorded. Ob-

servers had no verbal or physical interactionwith the patients.

All observations were recorded in time for-mat (ie, 2:30 PM) on data collection sheets.The sheets of the 2 research assistants werethen collected at the end of each observationsession. Using the patient physical descrip-tions (eg, gender, age, etc) as identifiers, it waspossible to link the observations of both ob-servers to calculate time data for the entire pa-tient visit.

Patient survey procedure

Every patient, on completing his or her visitto the clinic, was asked by a designated prac-tice staff member whether he or she wouldbe willing to fill out a survey for a study ofpatient satisfaction. Participation was volun-tary and survey responses were anonymous.Questions were about the waiting area andexamination room, interaction with staff, andoverall perceptions of quality of care. Patientswere given the choice of filling out the sur-vey before they left the clinic or taking thesurvey home and then mailing it back to theCornell researchers directly in a self-addressedand stamped envelope supplied to them. Ifthey completed the survey before leaving theclinic, they folded the survey and put it in asealed envelope and dropped it into a specialsurvey drop box placed on the counter in thereception area. These surveys were collectedweekly by the Cornell researchers.

Over the 15-week duration of the study, 205surveys were collected from the 7 practices.Although staff were instructed to ask all pa-tients to fill out a survey on the completionof their visit, on the basis of observations andtalking with staff only about 50% of the pa-tients were actually offered surveys. This fig-ure and the average number of patients sched-uled per day were used to calculate the ap-proximate response rates for each location.While the response rates were low (8%–20%),a comparison of the observed patient popu-lation demographics with the demographicsfrom the patient surveys indicated that thesurvey population was representative of thepatient population visiting the practice overthe course of the study.


Table 1. Averaged time findings for all locations

Standard Average percentage

Observed times findings Average deviation of total visit

Total time in clinic 1.03 0.34 100

Time spent with doctor 0.13 0.15 21

Time spent with all staff 0.17 0.15 27

Total wait time 0.48 0.31 76

Time in waiting area 0.23 0.47 37

Time in examination room 0:34 0.27 54

Time spent alone in examination room 0.18 0.23 29

Time in examination room till doctor entered 0.15 0.15 24

Quality and staff indexes

The final 4 questions on the patient sur-vey were combined and averaged to createa quality-of-care index that reflected patients’overall impression of their visit. The 4 ques-tions were as follows: (1) The care I receivedhere today was. . .; (2) The service I receivedhere today was. . .; (3) Overall, my interactionswith staff were. . .; and (4) Overall, my interac-tions with doctors were. . ..

Similarly, an overall staff-interaction indexwas calculated by averaging patient responsesfrom the following 4 survey questions: “Iwas treated with kindness and respect by thestaff,” “The office staff were helpful duringmy visit today,” “The value of my time was re-spected by the office staff,” and “The officestaff were friendly during my visit today.”

Data for both indices were analyzed interms of the percentage of respondents whoreplied to survey questions with an “Excel-lent” response because research has shownthat there is a significant difference in per-ception between respondents who respondwith the highest possible rating and thosewho do not. Responses in the “top box”characterize patients who become intenselyloyal customers, leading to greater marketshare and achievement of financial objectives(Marberry, 2006; Press Ganey Associates,2006).

Actual versus perceived time

In addition to the times recorded by the re-search assistant in each location, patients’ per-

ception of how long they waited in the wait-ing area and in the examination room was as-sessed on the survey.

FINDINGS

Attractiveness of the

physical environment

Independent rankings of the attractivenessof the physical environment ranged from 34(most attractive) to 9 (least attractive). Pa-tients in each practice were also asked ques-tions about their perception of the pleasant-ness of the physical environment on their sat-isfaction surveys. The correlations were sig-nificant between the independent panel en-vironmental ranking and “The waiting areawas pleasant” (r = 0.617, P < .01) and “Theexamination room was pleasant” (r = 0.528,P < .01). There was also a positive correlationbetween those 2 patient-reported measures(r = 0.456, P < .01). These positive corre-lations indicate overall consistency betweenperceptions of the patients in the practicesand independent observers.

Observed time findings

Table 1 shows the overall time findings forall patients observed in all locations.

The average percentage of total visit wasdetermined by dividing that time category by63 minutes, the average total time across allpractices.


Figure 1. Actual time versus perceived time in waiting area, all locations.

Actual time versus perceived time

Results (Table 1) showed that patientsspent approximately three quarters of theirvisit waiting, and almost a third of their visitwaiting alone in the examination room. Whenactual and perceived times were compared,patients tended to overestimate shorter wait-ing times and underestimate longer waitingtimes. That is, more people said they waited0 to 5 minutes, the shortest waiting time cate-gory on the survey, than were observed wait-ing that long; and more people were observedwaiting for more than 30 minutes, the longesttime category on the survey, than reportedwaited that long. This pattern was true forwaiting times in both the waiting area and theexamination room before the doctor entered(Figures 1 and 2). The same pattern held whencomparing practice types, with the excep-tion of the gastroenterology practices wait-

Figure 2. Actual time versus perceived time in examination room untill doctor entered, all locations.

ing areas. Here, no relationship was found be-tween the attractiveness of the environmentand perceptions of waiting a short time. Thelack of difference in the shorter time cate-gory may be due to the fact that, in compar-ison to the other practices, very few patientswaited less than 5 minutes in either gastroen-terology practice. No significant relationshipswere found between any of the observed timemeasures and patient perceptions or betweenactual time measures and rankings of attrac-tiveness.

Overall, patients who responded that theywaited less than 5 minutes had significantlyhigher perceptions of quality of care (18%higher for time in the waiting area and 26%for waiting time in examination room) andhigher perceptions of the environment reduc-ing their anxiety (23% in the waiting area and38% in the examination room) than patients


Figure 3. Perceived time in waiting area; quality-of-care index and anxiety relief, all locations.

who reported waiting more than 30 minutesin each of those locations (Figures 3 and 4).

Comparisons of patient perceptions of theirlength of wait in the waiting area and exam-ination room to the quality-of-care and staff-interaction indices showed that patients’ waittime in the examination room before the doc-tor entered more strongly correlated withtheir overall perceptions than their wait timein the waiting area (Table 2). The correlationsare positive because of the initial coding ofpatient responses, in which shorter waitingtimes were higher numbers so that higher re-sponses indicated a more positive experiencethroughout all data.

Patient perceptions of quality andanxiety

There were significant correlations be-tween the overall patient-quality index and at-

Figure 4. Perceived time in examination room until doctor entered; quality-of-care index and anxietyrelief, all locations.

tractiveness of the physical environment (r =0.335, P < .01), and between relief of patientanxiety and the attractiveness of the environ-ment (r = 0.294, P < .01).

Survey responses from the environmentswith the largest difference in attractivenessrankings were then compared. Patient percep-tions of quality of care, anxiety, feeling caredfor, and the likelihood of recommending thepractice to others were, on average, twice ashigh in the most compared to those in theleast attractive physical settings (Figure 5).

Because the amount of patient anxietylikely varies by practice type, analyses com-pared the levels of reported anxiety reductionrelated to environmental attractiveness foreach practice type (Table 3). Results showedthat within each of the 3 practice typesexamined (dermatology, gynecology, and gas-troenterology), the more attractive physical


Table 2. Correlations of waiting time in waitingarea and examination room before doctor enteredwith quality-of-care and staff-interaction indexes

I had to I had to

wait too wait too

long before in the

being called examination

into the room before

examination being seen

Indexes room by the doctor

Quality-of-care 0.199 0.345

index

Staff-interaction 0.290 0.412

index

environment had a higher percentage ofreported anxiety reduction.

The relationship between the physical en-vironment, reduction of patient anxiety, andoverall patient perception of quality wasexamined further using regression analysis(Table 4). Linear regression showed that theattractiveness of the physical environmentwas a significant predictor of the patient’s per-ception of quality of care as well as the reduc-tion of patient anxiety, controlling for practicetype in both analyses.

Figure 5. Patient perceptions of quality, anxiety, feeling cared for, and likelihood of recommendation;most- and least-attractive practices.

Patient perceptions of staff interaction

Staff-interaction indices, by location, areshown in Figure 6, along with the rankingof attractiveness of each location. The staff-interaction index and the overall quality-of-care index were significantly correlated (r =0.504, P < .01), as were the staff-interactionindex and the attractiveness of the environ-ment (r = 0.352, P < .01). There was norelationship between the patient-to-staff ra-tio of a practice and the patient’s perceptionof staff interaction. Significant correlationswere found between the staff-interaction in-dex, quality-of-care index, and the attractive-ness of the environment (Tables 5 and 6).

DISCUSSION

These findings are consistent with the re-sults of Arneil and Devlin’s (2002) study,which found that perceived quality of carewas greater for rooms that contained nicefurnishings, artwork, and lighting, and werewarm in appearance than those that did not;and with the findings of DeMan et al. andDansky and Miles, who found significant dif-ferences between perceived and actual wait-ing time and significant relationships between


Table 3. Attractiveness of environment, anxiety relief, quality-of-care index and likelihood of recommen-dation by location and type of practice

Attractiveness Anxiety, Overall Recommendation,

rating % quality, % %

Dermatology

Iris Cantor, 10th-floor,

Dermatology

25 22 70 55

Starr 326, Dermatology

Practice

9 8 61 44

Gynecology

Iris Cantor, Women’s Health

Center: Gynecology

25 24 78 63

J130 Obstetrics and

Gynecology

21 14 84 64

Gastroenterology

Jay Monahan Center for

Gastrointestinal Health

34 54 86 81

Iris Cantor, 10th-floor,

Gastroenterology

25 40 79 55

J314 Gastroenterology 12 0 40 34

perceived waiting times and satisfaction withthe visit and quality of care (Dansky & Miles,1997; De Man et al., 2005).

There are several possible explanations forthe relationship of the attractiveness of the en-vironment with the patient’s perceived qual-ity. As Arneil and Devlin (2002) stated, themost obvious explanation might be that whenpatients perceive that a physician or otherstaff have put effort and care into the waiting-room environment, they assume that samelevel of care and concern will be given tothem as a patient in that facility. Researchhas also shown that patients tend to be over-whelmed with the technicality of their med-

Table 4. Regression of attractiveness of physical environment and quality-of-care index on reduction ofpatient anxiety, controlling for practice type

Predictor R2 ER2 FER2 df1 df2 Significance

Attractiveness of environment 0.13 0.04 9.02 1 186 .000

Quality-of-care index 0.48 0.15 36.14 1 181 .000

Attractiveness of environment, controlling 0.49 0.01 1.29 1 180 NS

for quality

ical visit, so in lieu of the things they cannotunderstand (such as procedures, terminology,and medical equipment), they rely more heav-ily on things that are familiar and cues theycan interpret, such as their physical surround-ings (Berry & Bendapudi, 2003).

This concept of using the physical environ-ment as a way to communicate organizationalvalues as well as creating a more positiveexperience for the patient is at the core of thepatient-centered care movement advocatedby organizations such as the Planetree Foun-dation, The Center for Health Design, andthe Institute for Healthcare Improvement.The Planetree organization, for example,


Figure 6. Staff-interaction index by location, with attractiveness ranking.

advocates the use of domestic-inspired aes-thetics, art and warm home-like, noninstitu-tional designs that are familiar and welcomingand value patients over technology. Plane-tree design guidelines seek to achieve thisexperience by encouraging the use of woodand natural colors and materials (Schweitzeret al., 2004). Design recommendations suchas these aim to utilize the environment as away to inform the patient about the qualityof care at that facility, as well as to reducesome of the anxiety that patients frequentlyassociate with medical visits.

Environmental attractiveness and

patient perceptions of staff interactions

The significant relationship between envi-ronmental attractiveness and patients’ posi-tive impressions of interactions with staff in-

Table 5. Correlations of patient perceptions and attractiveness of the environment (all correlations signif-icant at the P < .01 level)

Attractiveness Quality-of-care Staff

Measure ranking index index

Attractiveness ranking 1.00 . . . . . .

Quality-of-care index 0.335 1.00 . . .

Staff index 0.352 0.504 1.00

The office environment helped to ease my

anxieties about my visit

0.294 0.369 0.422

I would recommend this office to others 0.282 0.530 0.709

Overall, I felt cared for as a person during my visit 0.340 0.520 0.659

I was made to feel welcome during my visit 0.280 0.510 0.711

teraction support previous findings that havefound subjects to have more positive impres-sions of people while in more attractive envi-ronments (Maslow & Mintz, 1956). Althoughvariation in actual staff behaviors in differ-ent environments is not discernable from thisstudy, the strong relationship between the pa-tient’s impression of their interaction withstaff and their overall impression of qualityof care, supports previous research that com-munication and interpersonal relations withcaregivers play a vital role in the patient’s per-ceptions of their visit (Powers & Bendall-Lyon,2003; Saultz, 2003).

Environmental attractiveness and

perceived waiting times

While significant relationships were foundbetween patient perceptions of time and


Table 6. Regression of attractiveness of physical environment and quality-of-care index on staff interactionindex, controlling for practice type

Predictor R2 ΔR2 FΔR2 df1 df2 Significance

Attractiveness of environment 0.33 0.10 19.40 1 179 .000

Quality-of-care index 0.53 0.27 65.67 1 179 .000

Attractiveness of environment, controlling 0.54 0.18 46.13 1 178 .000

for quality

outcome measures of overall quality of careand relief of anxiety, no significant relation-ships were found between observed timemeasures with either quality of care or anx-iety responses. While previous studies haveshown a relationship between waiting timeand patient satisfaction (Dansky & Miles,1997), the lack of a relationship between ac-tual time and patient outcomes and the pres-ence of a relationship between perceived timeand quality of care in this study suggests thatpatient perceptions may play a more integralrole in the formation of overall quality and sat-isfaction impressions than actual time spent.If perceived waiting time is more importantthan actual waiting time, as the findings inthis study suggest, the further finding thatthe attractiveness of the physical environmentinfluenced perceived waiting times high-lights an important way in which the physi-cal environment can influence patients’ visitexperience.

CONCLUSIONS

This study shows that the physical environ-ment of healthcare facilities influences the pa-tient’s waiting experience and their percep-tion of quality of care. There is no one as-pect of the visit, or element of design, thatconclusively defines the patient experience.Rather, it is a combination of both physicaland social factors that influence both staff andpatients. Given tight budgets and cost con-straints in healthcare construction and reno-vation, it would be worthwhile to better un-derstand what specific environmental factorsand aesthetic details within the healthcare en-

vironment both staff and patients pay most at-tention to, and how those details impact staffbehavior and patients’ perceptions of theirwait and overall quality of care.

Ulrich (2001) and others talk about the im-portance of positive distractions, but too of-ten in waiting areas, these take the form of atelevision on the wall and a jumble of often-outdated magazines on a table. We found inthis study that computers intended for pa-tient use in 2 of the waiting areas studiedwere almost never used. Two factors seemedto account for this. On closer inspection, wediscovered that the computers were in factturned on, but the screens were set to black,with nothing showing. One row of comput-ers was also at counter height, with bar stool-type seating. As a mini-experiment, we setthe screen saver to show the desktop, andrepositioned a row of desk height computersso they were visible from the reception area.In 1 hour, as many of the computers wereused as in 10 weeks of observation. Healthpamphlets were almost never read or taken bypatients or visitors, despite being prominentlylocated in the waiting area. Future researchshould explore how relatively small designfeatures in the waiting-room environment,ranging from the provision of computers andinternet access to the use of fish tanks, waterfeatures, and so on affect perceived waitingtimes. More attention also needs to be paidto the positioning of seating. Even in expen-sive and beautifully designed waiting areas,the arrangement of chairs often more resem-bles what might be found in a bus station thanin, for example, a modern hotel lobby. Closelypacked rows of chairs provide no personal


space for people sitting next to each other,and could be expected to increase stress andanxiety and perceived waiting time. Researchon such details and their effects have the po-tential to enable healthcare organizations tomake small, focused changes within their ex-isting environments that can positively impactthe perceived quality of care.

Current hospital design devotes consider-able attention and resources to creating gen-eral waiting areas. Yet, we found that patientsspent almost a third of their visit waiting inthe examination room, typically alone andwith nothing to do or occupy their attention.More attention needs to be devoted to under-standing patients’ journey through their en-tire healthcare visit. With a more thoroughunderstanding of how space is actually used,we might pay more attention to areas such asexamination rooms than to the more publicand visible waiting areas that currently attractmore interest and resources, but have poten-tially less impact on the patient experience.

Much of the focus on “patient-centered de-sign” has been on creating more pleasant andcomfortable environments for patients andtheir family. Our findings, which are con-

sistent with the research noted above, indi-cate that paying attention to and investing re-sources in the quality of the physical settingspatients experience in obtaining healthcareare worthwhile. The significant relationshipbetween patients’ perception of their inter-action with staff and patients’ perception ofoverall quality of care underscores the impor-tance of also understanding how the physi-cal settings in which staff deliver care affectstheir attitude and behavior. “Patient-centeredcare”from this perspective must consider notonly the patient’s experience but also staff’s.Given that staff inhabit the healthcare facilityfor significantly longer periods of time than dopatients and their family and friends, and uti-lize it in different ways than the patients, bet-ter understanding the relationship betweenstaff and their environment is critical. Futureresearch should examine whether patients’more positive perceptions of staff in morephysically attractive environments are relatedto the halo effect of the environment, muchas Maslow and Mintz (1956) found 50 yearsago, or are related to staff-behavior patternswith patients that are actually more positivein more physically attractive settings.

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