Waiting rooms, too, can promote patient health
To provide a homier atmosphere and allow patients to sit apart from others if they choose, health care interior designers will arrange waiting room furniture in separated small groups. Art reflecting the natural world is intended to calm patients and remind them of happier moments in their lives. (Photo by Mark Trew, courtesy of HDR Architecture)
Patients often form their first impression of a medical practice in the waiting room, or reception area. Stained furniture, old magazines strewn about, rude front-office staff—such experiences have a huge impact on how patients perceive the quality of their care, says Arnold Melnick, DO, who has written on many aspects of medical communication.
Patients comment on wait times and room ambience on physician rating websites far more frequently than they criticize doctors’ clinical skills. What patients tend to remember about a medical visit and share with others is what they understand, says Rosalyn Cama, a health care interior designer in New Haven, Conn. Patients’ perception of their time in the reception area affects not only their opinion of the practice but also their health, she notes.
“What we do as health care designers is look at how to create an environment that will improve outcomes,” explains Cama, the author of Evidence-based Health Care Design. “We look at studies that answer such questions as, ‘How do you calm down anxious patients? How do you keep the environment clean and infection at bay? Given that physicians today have so little time to spend with each patient, what can be done in the reception area that will improve communication at the moment of physician-patient interaction?’ ”
The messages conveyed by a waiting room can be direct or subliminal. Everything from the arrangement of seating to the type and intensity of lighting has an impact on a patient’s mood and well-being.
Welcome to the practice
Al Turner, DO, of Portland, Ore., who retired last June, put a lot of thought into the design of his practice’s reception area, which, he insists, he never called a waiting room. “It is insulting for patients to make an appointment to wait,” says Dr. Turner, who had an osteopathic manipulative medicine practice.
“If you don’t have access to a lovely view, art that evokes beautiful images of the natural world has been shown to be really beneficial to patients.”
Dr. Turner chose to have a small reception space with just six chairs so he and the two DOs who practiced with him would have to be on schedule. “We were forced to be on time,” he says. “We didn’t have enough chairs for patients to stack up.”
It should go without saying that any medical waiting room ought to be welcoming and comfortable. But Dr. Melnick, who at age 93 has seen many doctors’ offices over the years, knows this is often not the case.
“When patients walk in, they should be greeted warmly,” Dr. Melnick says. Someone from the front office should go into the waiting room to see whether anyone needs special assistance, whether in filling out forms or in getting to the washroom. A patient with a walker or in a wheelchair may need additional help when his or her name is called.
Just like the attentiveness of staff, a waiting room’s appearance speaks volumes about the physicians in that practice. “The atmosphere is the doctor,” notes Dr. Melnick. “A sloppy doctor will have a sloppy atmosphere.
“In a doctor’s office, people expect cleanliness, and they expect the reception area to be neat. And neat means that somebody on the staff should check the waiting room every hour or two to make sure that magazines aren’t strewn around, that dirty coffee cups and used tissues aren’t left on tables, and that wastebaskets are emptied.
“A waiting room left alone from 9 in the morning until 3 in the afternoon is going to be a mess.”
The appearance of the reception area reflects the attitude and the habits of a practice’s physicians, agrees Kris Beavers, the executive director of the Texas chapter of the American College of Osteopathic Family Physicians, who was a practice manager for 10 years. “Your reception area teaches patients how you will treat them and how they should treat your office,” she says. “When patients come up to the window to check in for their appointments and that desk is a mess, with papers scattered everywhere, you are sending the message that maybe their health is not best in your hands.”
A messy reception desk and worn-out furniture in the waiting area also communicate that the practice doesn’t pay attention to billing and collections, Beavers points out. “You can let patients know without saying a word that your practice doesn’t collect co-pays and you don’t expect patients to pay their bills,” she says. “You can send a lot of subliminal messages just by the way your office looks.”
Dr. Turner came up with a way to keep his small reception area tidy. In other physicians’ waiting rooms, he had always hated the look of magazines, which invariably end up torn and dog-eared, as well as tossed about on tables, chairs and the floor. He also was disturbed by the trashy content of some of the magazines he saw. “I have gone into doctors’ offices where kids were running wild while parents had their noses in old issues of People magazine,” he says. “There is nothing healthy about that.
“In my practice, I directed all of my energy toward healing connections. I can’t think of anything healing or connecting about a two-year-old issue of People.”
So rather than subscribing to magazines for his practice’s reception area, Dr. Turner purchased a number of coffee-table books and displays five or six at a time in the room, rotating them every couple of months. Many of these books were about animals, with lots of photos of dogs, cats or horses. He also put out gardening books in the spring and travel books in the winter.
“Kids and parents are more respectful of books,” Dr. Turner explains. “The dog book was especially popular. Often kids would be on their mom’s lap, and they’d be going through the book, trying to find their own dog or their favorite dog. That’s a much more healing environment than a mom yelling at her kids because they are running all over.”
In addition to eschewing magazines, Dr. Turner recommends that physicians not display promotional materials from pharmaceutical companies or any products the practice might be selling, whether vitamin supplements or shoe insoles.
“I’ve gone into medical offices where it looks like drug companies provided the wallpaper,” he observes. “I never liked the feeling that I was a commodity.
“Generally, if I’m at a doctor’s office, I’m not feeling well to begin with. And then to be attacked by ads makes me feel worse.”
Practices that post their payment and cancellation policies everywhere put Dr. Turner off as well. “I understand that a practice is a business,” he says. “But there are a variety of ways of handling a business that are much more personal than that.” Dr. Turner suggests placing office policies in a three-ring binder “like you find in many hotel rooms.”
In addition to feeling sick, patients visiting a doctor may be anxious about the seriousness of their health problems. They also may be nervous about diagnostic tests or procedures to be performed.
To promote a healing environment, as well as dampen ambient noise, Dr. Turner mounted three decorative fountains with cascading water on one wall of his reception area. “Patients found them relaxing,” he says. “After driving an hour or so to see us, I wanted them to be able to relax and inhale a few times before being taken back into one of the treatment rooms.” The fountains also helped humidify an otherwise dry space.
Interior designers stress the importance of natural light in health care interiors. “If you’ve got a waiting room that has a view to the outdoors, to nature, it can be so much more calming an environment than if you are on the inside of a building with no access to daylight or a view,” says Jean Hansen, a San Francisco-based interior designer and HDR Architecture’s sustainable interiors manager. “If you’ve got great daylight coming in, you’re going to want your artificial lighting to dim or turn off when it’s appropriate and just let daylight flood the space.
“If there is a period of time with a lot of glare or a real bright light coming in, maybe the window shades need to come down for a short while. Ideally, an automated system would track the sun and move the shades up and down as needed.”
Natural light elevates mood and reinforces normal circadian rhythms, Cama adds. “Daylight is important to us as human beings. It sets our clock,” she says. “And it is as important for medical staff as it is for visitors. Not being exposed to a full spectrum of daylight disrupts your sleep patterns, your mood and your ‘food clock.’ ”
But in many medical office buildings, waiting rooms are situated off of interior corridors. Until recently, there hasn’t been an effective way to simulate daylight in a windowless environment using artificial lighting, Cama says.
But organic light-emitting diode, or OLED, technology shows promise in allowing artificial light to be carefully controlled. “The color spectrum can be dialed in and modulated so that you get warm light in the morning, cool light at noon and warm light at the end of the day, which simulates the effects of the sun,” Cama says.
Although such a high-tech system would be cost-prohibitive for a typical practice, medical offices can use LED instead of linear fluorescent light fixtures in waiting rooms, Cama suggests. In addition to being more energy-efficient, LED lighting is less intrusive and more soothing to waiting patients because it doesn’t flicker or hum.
“While we are waiting for the LED technology to mature, full-spectrum fluorescent lighting is a good alternative,” Dr. Turner adds. “Slightly more expensive than regular fluorescent lights but well worth the price, I enjoyed the health benefit of full-spectrum lighting throughout my office for 25 years.”
Artwork can help compensate for the lack of windows or a drab view of a parking lot. “If you don’t have access to a lovely view, art that evokes beautiful images of the natural world has been shown to be really beneficial to patients,” Hansen says.
“Daylight is important to us as human beings. It sets our clock. And it is as important for medical staff as it is for visitors.”
Art hung on waiting room walls should reflect regional tastes and interests, says Cama. “You can work with local artists who paint beautiful natural scenes,” she suggests. “In New England, families often go to the shore for relief on weekends. So if you put a long painting of a shoreline in a Connecticut medical office, chances are that some patients will look at it and remember a fun time they had last summer with their kids. They might say to themselves, ‘I’m not feeling well today. But let me just close my eyes and remember that moment again.’
“That painting helps the patient go to a happier place, which has a positive physiological response.”
The use of color in a room should also reflect regional sensibilities, Cama says. Colors that would be inviting to patients in the Southwest differ from those that would be appealing to patients in the Northeast.
On the wall opposite his cascading fountains, Dr. Turner displayed a set of five photographs depicting an Oregon woodland scene. He consulted a colorist to determine the best hues for his furnishings and finishes. “I said I wanted to portray strength and growth,” Dr. Turner remembers. “That moved us to green fabric on wood chairs—green representing growth and wood representing strength.”
Know your audience
Seating arrangements, furnishings and special amenities should be planned with the practice’s patient population in mind. Because some patients value their privacy and are concerned about other people’s germs, it’s better to have small groupings of chairs rather than chairs lined up side-by-side along the perimeter of the room, Cama says. Such arrangements allow family members to cluster together and create a homier atmosphere.
Waiting rooms in pediatric and family medicine practices should have a table on which students can do their homework, Cama recommends. Electrical outlets should be conveniently placed so students can plug in their laptops, tablets and other electronic devices. A Wi-Fi network should be available.
Such waiting rooms should also include a play area for young children with activity tables, wall panels and play cubes—easy-to-clean, built-in toys that encourage quiet exploration and don’t create a mess.
Patient demographics should be considered when selecting furniture. Practices that serve many geriatric patients should have some higher chairs with armrests so that individuals with hip problems can sit down and get up more easily. Foot stools should be available for patients who need to elevate their feet. The room should also have some wide chairs for obese patients.
Whether a waiting room should have a television, as many do, is a matter of debate. For walk-in clinics where the waits tend to be longer, a TV can help reduce boredom. But it also can add to stress because individuals may argue over which programs to watch. And some shows may be inappropriate for children or offend certain patients.
“I’ve been to practices in lower-income neighborhoods where patients were watching soap operas or ‘Judge Judy’ on TV,” Beavers notes. “That may not be in the best interest of small children.
“You have to look at your clientele. If you have a TV, give careful consideration as to how you would want your staff to handle a situation in which something on television is inappropriate. Sometimes it is better not to have a TV at all.”
News programs, talk shows and daytime dramas do not contribute to a calming, healing atmosphere and may send the wrong message to patients. In February, a community health center in Michigan caught the attention of national media for banning Fox News from its waiting room TV sets. The health center, which had been encouraging patients to sign up for insurance coverage under the Affordable Care Act, objected to the network’s persistent disparagement of the health care law.
In Cama’s opinion, a TV is unnecessary in the vast majority of medical waiting rooms. “Most people walk around with their own entertainment today,” she observes. “Televisions are an intrusion into what I am doing with my own device.”
However, video monitors in a reception area can be used for educational purposes, such as explaining osteopathic manipulative treatment, Beavers points out. The ACOFP has produced more than 100 video presentations on OMT techniques that could be in this way, she says.
An educational center within a reception area could also provide patients with nutritional information, Cama suggests.
Environmentally friendly space
Like other spaces in a medical facility, reception areas should be designed to minimize both germs and environmental health problems. But sometimes these goals seem to be in conflict. For example, strong cleaning solutions used to kill germs can cause respiratory problems. Live plants that can help clean the air may be problematic for patients with allergies, while artificial plants collect dust and may be difficult to clean.
“When patients come up to the window to check in for their appointments and that desk is a mess, with papers scattered everywhere, you are sending the message that maybe their health is not best in your hands.”
Hansen is especially concerned about semivolatile organic compounds that are present in both vinyl fabrics and the flame retardants commonly used in the manufacture of furniture upholstery foam. “There typically are plasticizers in vinyl fabrics that aren’t molecularly bound to the product, just like flame retardants aren’t bound to the foam used in seat cushions,” she explains. “These chemicals can be absorbed through our skin and settle on the floor in dust particles. Children can get this dust on their fingers and ingest it when they put their fingers in their mouths as they explore their environment.”
Consquently, Hansen recommends that waiting room seats be covered in environmentally friendly nonwoven fabrics that are non-vinyl, manufactured without flame retardants and easy to clean.
Waiting rooms in doctors’ offices are often carpeted to reduce noise. Nylon fiber carpeting, which is the most stain-resistant and durable type for commercial use, generally is designed to be cleaned without the use of soap or cleaning solutions, Hansen notes. If soap or cleaning solutions are used to clean the carpet, they tend not to be fully extracted and will attract additional soiling in the future due to sticky residue left behind on the carpet fiber. Medical practices and their interior design consultants, she says, must make sure that janitorial or environmental services workers understand which cleaning products can and cannot be used on floors, walls and other surfaces in the reception area.
Osteopathic physicians’ whole-patient approach to care should extend to the reception area, Dr. Turner says. Research supports the need for patient-centered design in medical settings.
In 2008, the Journal of Ambulatory Care Management published a study examining the relationship between a medical facility’s physical environment and patients’ satisfaction with their care.
The authors concluded that “the physical environment of health care facilities influences patients’ waiting experience and their perception of quality of care. There is no one aspect of the visit, or element of design, that conclusively defines the patient experience.” Rather, a combination of both physical and social factors influences patients, the article noted.
Physicians nowadays are under more and more external pressure to provide patient-centered, high-quality care, and they must assess their own performance with patient-satisfaction surveys and other quality metrics, Cama points out. “In the old model, it was all about the physician,” she says. “Today, it’s about understanding your patients’ experience, being empathetic, walking in their shoes.
“It’s not about the patient just sitting in the chair, waiting.”