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Recently, I looked at the HCAHPS survey summary analysis and saw that the question about hospital noise is still the lowest scoring question of  the bunch.

During this hospital stay, how often was the area around your room quiet at night?

The average score reported in July 2013 was 60% — up from 54% when scores were first reported in March 2008. But still the lowest of the average “top-box” scores for each of the 10 HCAHPS measures at the state and national level.

Why is this? Maybe we should ask hospitals in Louisiana, because they scored 71%, up from 67% five years ago.

It will probably take a lot of work to get the overall score in the 80th percentile. But why not make that a goal?

Achieving it will not only require addressing operational and cultural issues, but the design of the physical environment as well. Some well-known architectural and interior design strategies for creating quieter environments are:

  1. Single patient rooms
  2. Examination and treatment rooms enclosed with walls
  3. Private discussion areas in admitting areas and on units
  4. High-performance sound-absorbing acoustical ceiling tiles
  5. Effective wall and furniture design and layout
  6. Decentralized or “distributed” nurse stations
  7. Carpet or sound-absorbing flooring material

In my work with Healing HealthCare Systems (HHS), producers of The C.A.R.E. Channel, I’ve also learned that relaxation programming on patient television can also help mask unwanted hospital noise — or distract patients so they don’t hear it and are comforted.  In other words, not all sounds are bad sounds.

According to Susan Mazer, Ph.D, President and CEO of HHS, “quiet is not a decibel level; quiet is an experience of calm, of peacefulness, a feeling of safety. Deadening silence is frightening.  Erratic noises that are perceived as foreign and invasive, are agitating.  Therefore, a patient’s own living of those long night hours is best served by designing the experience.”

Mazer also thinks the question on the HCAHPS survey is ambiguous, telling us “very little about what is happening in the room and whether the lack of noise was comforting.”  She believes it’s probably not realistic to expect that patients will answer “always” to the question of how often they experienced quiet around their room at night, because hospitals are alive 24/7 with activities going on all the time.

So, until we look at the issue of noise differently in hospitals, perhaps the HCAHPS noise question score will never significantly improve.

But there’s lots of available information to help guide those who are dealing with this issue.  HHS has published several whitepapers on reducing hospital noise, as have the Beryl Institute, and The Center for Health Design. And, the Joint Commission recently issued a sentinel alert on alarm fatigue, which is illustrated in this cool infographic.

Most importantly, let’s keep the dialogue going.

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David Sykes

6 years ago

The best and most complete answer to your question was delivered last week by Gary Madaras PhD, AIA, ASA, at the Acoustical Society of America conference in San Francisco. Bottom line: hospitals that followed the 2010 FGI Guidelines acoustical criteria appear to perform very well on the HCAHPS “Quiet at night” question. And published case studies of several of these are worth careful reading by planners and designers (examples: two projects that won awards of merit in the Sept. 2012 edition of Healthcare Design magazine have excellent acoustics; one project was led by Kurt Rockstroh FAIA, FACHA, president of FGI and the architecture firm SBA and is being analyzed now as part of a cost-benefit study; the other was done by NBBJ at MGH in Boston with assistance from a well-known acoustical consultant in NYC. Unfortunately, the reviews of these two projects failed to mention the improved acoustics or to describe what was done to achieve them). Gary Madaras’ presentation last week, and a new chapter in “Sound & Vibration 3.0” (scheduled to appear from FGI and Springer Verlag in the spring), detail the kinds of decisions made by planning and design teams that make a difference and significantly improve HCAHPS scores. Sadly, many hospital planning teams have not yet realized that: (a) it makes sense to address the HCAHPS “Quiet at night” question, or (b) they assume that the problem can be solved purely through operational/equipment changes (this doesn’t work). So while the 2010 Guidelines–containing the first comprehensive acoustical criteria in 60 years–were published three years ago, we are only now beginning to see hospital planning and design teams paying careful attention to the “Quiet at night” question proving that economic incentives are driving the change. As you know, we first talked to Press Ganey about this issue in 2004, so it has taken a long time to get hospital planning and design teams to understand the importance of making these needed changes.

Sara Marberry

6 years ago

Thanks, David, for your comments. And while I think the design of the physical environment is a critical component to reducing noise, hospitals must also look at operational and equipment issues as well. It’s not one thing or another. It’s both.

David Sykes

6 years ago

Please note: (1) the Beryl Institute report you cite was written by Gary Madaras PhD (the expert I mentioned above, whose work is widely read and who is a contributor to the FGI Guidelines); (2) the Center for Health Design magazine “Healthcare Design” (in the September awards issue) cites TWO case studies where the acoustics improvement are significant and resulted from following the FGI 2010 Guidelines (facts noted by both hospitals); (3) several prominent people from FGI, Joint Commission, AORN, CHD and other organizations are presently engaged in the “alarm fatigue task force” that is currently underway; and (4) it is inappropriate to state–when there is clear, publicly available evidence to the contrary–in the Center’s own journal–that “perhaps the HCAHPS noise question score will never significantly improve.” That is plainly untrue.

Sara Marberry

6 years ago

Hi again David. I know who Gary Madaras is and have followed his work for several years. I have high hopes that the HCAHPS noise question score will improve, and know that all this good work is being done. But so far, the HCAHPS noise question score has not significantly improved. Perhaps it will just take some more time?

Troy Tucker

6 years ago

Good points! These are complicated structures with lots of pieces to consider and each delivery approach comes with its own Pros/Cons. Certainly, acoustics are not given deserved consideration. As with much of the change taking place in healthcare planning and development right now, there seems to be a lag between the understanding of patient outcomes and surveys and their connection with the built and operational environments. Many times this disconnect is just as prevalent between caregivers and their administrators. Caregivers know what doesn’t work and even sometimes have a clue what will work but the admin team who ultimately makes the decision to pay for the change is typically not informed. Further, the design and planning team is tasked with keeping costs under control in one of the most expensive building types and acoustics are an easy target for value engineering if even considered. We need to close this gap between design/planning professionals and healthcare providers. We all have our strengths but we’re even better as collaborators. One objection I would make to the above is even the mention of carpet in a care wing. The infection control nightmare that this introduces is simply not acceptable.

Sara Marberry

6 years ago

Thanks for your comments, Troy! Lag time is truly an issue for design innovation. Not sure about your view on carpet. There are good anti-microbial options available. Carpet people, weigh in.

Troy Tucker

6 years ago

Teach me something…

Don’t get me wrong, I would love to see carpet perform well in this environment as it certainly brings some great advantages. Even with the current advances in anti-microbial products, the cleaning requirements to maintain sterility and product life in these high traffic and rolling equipment environments become financially challenging.

Tell me there’s a miracle product out there that I don’t know about and I’m all in.

Marjorie Serrano

6 years ago

Flooring is a multi-faceted issue with no simple answers. As for carpet, mobile equipment, and infection control, let’s be reasonable. We are not in the habit of dragging patients across the floor so airborne particles rather than sterility should be the concern. Consider this–There are NICUs with carpet chosen for the noise dampening effect and no increased infection issues in many years of use. Cleaning methods and the noise and disruption they produce should also be considered in all flooring decisions.

Marjorie Serrano

6 years ago

Until this operational issue is addressed, most improved acoustical design is negated: CLOSE THE DOOR! I often think the worst day in healthcare design was when fire codes were changed to no longer require automatic closers on corridor doors. If you ask nurses why they keep doors open, they cite the need to hear their patients. Let’s ask patients. Even better, let’s measure the noise level with doors open vs closed.

In regard to “not all sounds are bad sounds”, noise rather than sounds (or decibel level) is the issue. Natural sounds such as the wind in the trees may be very loud, but few humans would describe that as “noise.” Unfortunately, we all live in such a noisy world of man made sounds that we are poor judges of the negative affect on our bodies. Perception of noise may not be the best measure. Caregivers, and even patients, often think they can tune out noise but the negative physiological effects are still measurable.

Sara Marberry

6 years ago

Great comments, Marjorie. Thanks!

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Sara Marberry, EDAC, is a healthcare design knowledge expert, thought catalyst, and strategic marketing and business development consultant. The author/editor of three books, Sara writes and speaks frequently about industry trends and evidence-based design. She can be reached at [email protected].

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