Gary Madaras, Ph.D. – gmadaras@makinghospitalsquiet.com
Making Hospitals Quiet
4849 S. Austin Ave
Chicago, IL 60638
Popular version of paper 4aAAb3
Presented Thursday morning, October 25, 2012
164th ASA Meeting, Kansas City, Missouri
The noise plague inside hospitals has persisted for over a century. Only recently has a perfect storm of incentives, including patient- and family-centered care, evidence-based design, public transparency of quality measures and cuts to Medicare financial reimbursements resulted in a growing focus to decrease noise.
The frequency at which patients experience quietness at night is surveyed using the Hospital Consumer Assessment of Healthcare Providers and Systems questionnaire (HCAHPS). The most current summary of survey results shows patients score quietness the lowest out of all the quality factors being assessed. Only 59 percent of the time do patients respond that the areas around their rooms were "always" quiet at night. This low quietness score indicates patients are not getting the restorative sleep needed, resulting in worsened medical outcomes and increases in readmission and mortality rates. The Centers for Medicare and Medicaid Services (CMS) have identified indicators of low quality in hospitals, such as high noise levels, that lead to increased Medicare costs for the nation. In an effort to curtail increasing Medicare costs in the future, the Centers created its Value-Based Purchasing program. Simply put, hospitals that do not score well on the patient HCAHPS survey are reimbursed less by Medicare for the care of Medicare patients beginning this month, October 2012. Many hospitals are now scrambling to find ways to reduce noise levels for patient, staff and financial well-being.
One might theorize that new hospitals which are more likely to have private patient rooms and other features such as decentralized nurses' stations will naturally cure the noise plague as older hospitals are gradually replaced. However, ongoing research currently being conducted at Making Hospitals Quiet is investigating whether recently built hospitals are scoring any better on the quiet at night HCAHPS question than the national average. Preliminary results show that twenty-five new, ground-up, hospitals built between 2005 and 2011 have an average HCAHPS quietness score of 60 percent, one percentage point higher than the national average. As this research continues, the question as to whether a patient is more likely to receive an undisturbed, healing night's sleep in a newer hospital as compared to an older hospital will be investigated further.
A 2011 research project called The Hospital Noise Project was conducted by Making Hospitals Quiet and The Beryl Institute. The leaders from 241 existing hospitals, all trying to reduce noise, participated and shared their experiences with noise-reduction challenges, success stories and lessons learned. The findings showed that there are two significant components of a hospital's soundscape. The first is the physical factors of the environment, such as equipment alarms, doors opening and closing, nurse calls, paging and TVs. The second component is the culture, beliefs and behaviors of the people, such as visitation policies, night time admission protocols, rounding practices and shift changes. One the biggest noise-related challenges is organization-wide lack of awareness, accountability and buy-in when it comes to noise-reduction initiatives. While most staff persons will agree that quietness is a good thing, ultimately very few view noise as anything more than an inconvenient annoyance. In order to decrease noise, a culture shift in the organization toward recognizing noise as a serious health risk must be achieved.
The study also showed that hospitals trying to reduce noise tended to focus on the environmental aspects such as changing squeaky castors on carts and to a lesser extent 'quick fixes' for behavior change such as posting signage in corridors reminding staff and visitors to be quiet. Very few hospitals took a more structured and aggressive approach to assessing their culture and addressing the necessary behavior changes head on. Overall, only 12 percent of study participants rated the success of their noise reduction efforts as 'good' or 'great'.
This begins to explain why new hospitals may not be sufficiently quieter from the patients' perspective. Typically, the scope of the teams designing new hospitals is limited to the physical building and systems going into it. Conversely, no one is assessing the existing culture of the people using the hospital including their practices and policies of care, designing a plan to change it and building an organizational culture of quiet. Both components, the physical environment and culture, are critical for achieving quietness in both our existing and new hospitals. One component cannot compensate for the absence of the other. Great strides have been made in creating better healing environments, but until the missing scope related to staff and organization beliefs and behaviors about noise is addressed equally, it is unlikely that patients will experience undisturbed, restorative sleep in our nation's hospitals.