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Social Science & Medicine 75 (2012) 1057e1066

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Social Science & Medicine

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Building patient-centeredness: Hospital design as an interpretive act

Elizabeth Bromley a,b,*

aCenter for Health Services and Society, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, USAbVA Desert Pacific Mental Illness Research, Education and Clinical Center (MIRECC), West Los Angeles VA Healthcare Center, USA

a r t i c l e i n f o

Article history:Available online 26 May 2012

Keywords:Patient-centerednessHospital designUSAMedical professionalismConsumerismPatienthood

* Center for Health Services and Society, Departmbehavioral Sciences, University of California, Los Angele

E-mail address: ebromley@ucla.edu.

0277-9536/$ e see front matter � 2012 Elsevier Ltd.doi:10.1016/j.socscimed.2012.04.037

a b s t r a c t

Hospital designs reflect the sociocultural, economic, professional, and aesthetic priorities prevalent ata given time. As such, hospital buildings concretize assumptions about illness, care and healing,patienthood, and medical providers’ roles. Trends in hospital design have been attributed to theincreasing influence of consumerism on healthcare, the influx of business-oriented managers, andtechnological changes. This paper describes the impact of the concept of patient-centeredness on thedesign of a new hospital in the USA. Data come from 35 interviews with planners, administrators, anddesigners of the new hospital, as well as from public documents about the hospital design. Thematiccontent analysis was used to identify salient design principles and intents. For these designers, admin-istrators, and planners, an interpretation of patient-centeredness served as a heuristic, guiding the mostbasic decisions about space, people, and processes in the hospital. I detail the particular interpretation ofpatient-centeredness used to build and manage the new hospital space and the roles and responsibilitiesof providers working within it. Three strategies were central to the implementation of patient-centeredness: an onstage/offstage layout; a concierge approach to patients; and the scripting ofcommunication. I discuss that this interpretation of patient-centeredness may challenge medicalprofessionals’ roles, may construct medical care as a product that should sate the patient’s desire, andmay distance patients from the realities of medical care. By describing the ways in which hospital designsreflect and reinforce contemporary concepts of patienthood and caring, this paper raises questions aboutthe implementation of patient-centeredness that deserve further empirical study by medical socialscientists.

� 2012 Elsevier Ltd. All rights reserved.

Introduction

In The Cultural Geography of Health and Healthcare, WilbertGesler (1992a) encourages health scholars, “. to read or decodehealing environments for their symbolic meaning” (cited in Kearns& Barnett, 1997, p. 182). Hospitals can be particularly replete withmeaning because their designs result from the sustained deliber-ation of numerous situated actors weighing an array of priorities(Curtis, Gesler, Fabian, Francis, & Priebe, 2007). Designers andplanners build hospitals as efficient machines to manage the socialand material work of healthcare delivery (Cama, 2009). Providersand administrators also vie to articulate their visions of healing, ofhealth, and of death through hospital design (Risse, 1999). Archi-tects view the hospital as a public space that orients visitors toa particular vision of charity or social engagement (Stevens, 1999).

ent of Psychiatry and Bio-s, USA. Tel.:þ1310 794 3734.

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In these ways, hospital designs e where rooms are situated, wherenurses work, what lobbies look like e are historically and culturallycontingent; and trends in hospital design are prone to radical shiftsdriven by economic, professional, demographic, and technologicalforces (Rosenberg, 1995). As a flexible stylistic object, or whatscience and technology scholars call a niche innovation (Schot &Geels, 2008), the hospital constitutes a concrete representation ofthe prerogatives, theories, and preferences that prevail in a localcontext at a moment in time.

This paper argues that hospital designs can also encapsulate andcommunicate prevalent assumptions about the patient and care ofthe sick. One prominent recent trend in hospital and healthcaredesign focuses on improving the patient experience through theprovision of amenities and attention to patient concerns andcomfort (Goldman, Vaiana, & Romley, 2010; Bernstein, 2012).Design features that provide space, homey environments, andhotel-like services for patients and visitors are increasinglycommon. This is the first in a series of papers that empiricallyexamine the impact of this trend on staff and patient experience inthese types of settings. The findings from this study are necessarily

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provisional because they come from close study of a single hospital,but the data are presented as a means to generate hypotheses andraise questions for further research. In this paper, I use interviewswith designers and planners to describe the choices made aboutthe configuration of the hospital and thework processes that wouldtake place in it. Subsequent papers will examine the experience ofnursing staff and patients in the hospital.

If, as Risse (1999) says, the generic hospital is an abstraction andeach hospital is particular, then this hospital may be particular inthe coherence of the vision that guided its construction. Designersand planners envision this hospital building as a technology for thedelivery of patient-centeredness. During planning, the patient-centeredness concept operated as a potent conscription device,enlisting, motivating, and organizing collective effort (Henderson,1991). Since the opening, the patient-centeredness concept hasshaped hospital priorities and policies. This paper reviews currentscholarship on the concept of patient-centeredness and thendiscusses the specific interpretation of patient-centeredness thatdrives decision-making about space, sociality, and work in this newbuilding. Informants speak in consistent and detailed ways aboutthe tasks above and beyond the basic provision of medical treat-ment that the hospital strives to provide. Their choices raise a set ofquestions about the implementation of the concept of patient-centeredness in contemporary healthcare settings including therole of professional and technical expertise in patient-centeredenvironments, the content and components of caring that can benurtured in patient-centered spaces, and whether and in what waypatient-centered designs empower patients and engage them intheir care. Implementations of patient-centeredness deserveempirical study both because they aim to solve critical problems inhealthcare and because they may expose shortcomings in currentconcepts of patienthood, providerepatient relationships, andcaring.

Patient-centered care

Few slogans in today’s healthcare environment are as ubiquitousas patient-centeredness (Mead & Bower, 2000). Health scholars,administrators, marketers, and patient groups advance patient-centeredness as a strategy to restore the qualities of theproviderepatient relationship that they believe have been displacedby medicine’s specialization, bureaucratization, and reliance ontechnology. These advocates lament what they view as the devalu-ation of the patient e seen now to speak only passively through herlab results e and invoke patient-centeredness as a technique toacknowledge the patient’s intrinsic worth (Beach et al., 2005;Berwick, 2009). Among other goals, advocates of patient-centeredness aim to restore psychosocial concerns to a centralplace in medical encounters, involve patients more fully in medicaldecision-making, and support continuity in the doctorepatientrelationship. Patient-centered care models often prioritize commu-nication (Bensing, Verhaak, van Dulmen, & Visser, 2000), suggestingthat through patient-centered communication, “the potentialpaternalism of the physician is diminished and the empowerment ofthe patient is possible” (Mayes, 2009, p. 483).When scholars use thepatient-centeredness concept to focus on provider communication,it is seen to be practiced when physicians listen fully, exhibitcompassion, and endeavor to engage the patient (Krupat, Bell,Kravitz, Thom, & Azari, 2001; Langewitz, Eich, Kiss, & Wossmer,1998). When the patient-centeredness concept focuses onpatients, it views patient-centered care as closely congruent with,and responsive to patients’ wants, needs and preferences (Balint,1969; Berwick, 2009). Mead and Bower (2000) suggest that, “theconcept of ‘patient-centredness’ is increasingly regarded as a proxyfor high-quality interpersonal care” (p. 71). Despite e or perhaps

because of e the elusiveness of the patient-centeredness concept(Mayes, 2009), it is nearly universally endorsed (Laine & Davidoff,1996) and is often presented as inherently superior to any alterna-tive approach onmoral grounds at the least (Duggan, Geller, Cooper,& Beach, 2005; Haidet, Fecile, West, & Teal, 2009).

Yet medical anthropologists have articulated compellingcritiques of many aspects of this notion of patient-centeredness. Forinstance, patient-centeredness constructs the patient as a self-contained actor who arrives at the medical encounter withexplicit, fixed priorities (May & Mead, 1999) and then seeks tonegotiate with the provider to match care to his or her uniquedesires. Many medical anthropologists disagree with this charac-terization. Having jettisoned the concept of a sick role (Parsons,1951), they emphasize that the patient is co-constituted withinparticular contexts and institutional settings (Barrett, 1988; Ivry,2009; Lester, 2009). Velpry (2008) critiques the idea that thepatient’s view “is inherently present and that to elucidate it isempowering” (p. 239), arguing that the patient’s point of viewnecessarily emerges jointly with others. Mol (2008) critiques theprioritization of choice and autonomy. She questions whether thepatient’s ability and responsibility to choose is an unalloyed good.Mayes (2009), using a Foucauldian analysis, questions the all-or-none assumption that the physician possesses power while thepatient lacks it. Mayes asserts that patient-centered communica-tion introduces new power dynamics that operate in generativeways to structure the possibilities for patient and provider action.Potter and McKinlay (2005) go even further, suggesting that it is nolonger appropriate to view the doctorepatient relationship asa relationship at all. They argue that medical encounters are moreakin to instrumental exchanges that lack longitudinal continuityand interpersonal depth. They suggest that, increasingly superficialand focused on the here and now, the realities of such exchangesshould no longer be obscured behind the inaccurate label ofrelationship.

While these scholars debate whether patient-centerednessmakes sense in theory, others explore whether patient-centeredness is good in practice (Epstein et al., 2005; Zandbelt,Smets, Oort, Godfried, & de Haes, 2006). The answer dependslargely on how patient-centeredness is interpreted and imple-mented in particular contexts. I view hospital design as a particu-larly rich site for exploration of the implementation of patient-centeredness because hospitals are emergent objects, not merepassive landscapes (Gesler, 1992b) where healthcare happens(Sloane & Sloane, 2003). Hospital designs reflect the aspirations ofthose who manage them, and they reveal presumptions about theroles of healthcare providers (Watson, 2005). Moreover, “health careis continually reproduced in places by workers” (Andrews & Evans,2008, p. 759), and, as such, hospitals are responsive and adaptivesites. They can reflect shifting views of patienthood (Risse, 1999) aswell as evolving ideas about the societal role for healthcare insti-tutions (Curtis, Gesler, Priebe, & Francis, 2009). Stevens (1999) callshospitals, “organizational chameleons” (p. xi), flexible in repre-senting various social and organizational identities. For instance,beginning in the 1970s (Tomes, 2006), hospital designers built morefamiliar and approachable hospitals, including by moving them tocommercial areas where hospitals would, “share society’s drive forconvenience and service” (Sloane & Sloane, 2003, p. 7). Morerecently, hospital designs began to display the influence of anincreasingly professionalized, business-oriented group of hospitaladministrators (Swayne, Duncan, & Ginter, 2008) and their newmanagerialism, with its emphasis on standardization, the elimina-tion of waste, and the creation of value streams (Beardwood,Walters, Eyles, & French, 1999; Waring & Bishop, 2010).

Simultaneously, physicians and hospital administrators havewelcomed some of these changes in response to a series of internal

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challenges to hospital work. For instance, many systems adopttechniques of standardization and accountability to addressinconsistencies in the quality of medical care (Institute of Medicine,2001; Schuster, McGlynn, & Brook, 1998) and the alarmingly highincidence of medical errors (Hayward & Hofer, 2001). The role oftechnology in the provision of healthcare continues to accelerate. Inaddition, physicians who specialize in inpatient care (i.e., hospi-talists) increasingly provide patient care in hospitals. Hospitalistshave been key to managing the short lengths of stay and the highlyspecialized treatments required by the severely ill patients whoremain in hospitals (Wachter & Goldman, 2002). In such a technicalcontext where care tends to be discontinuous with outpatientsettings, hospital administrators may understandably view effortsto make hospitals more friendly and approachable as highly rele-vant. At the same time, of growing importance to hospitals’ stra-tegic plans is the marketing of amenities and services that areattractive to physicians and their patients, particularly in the U.S.(Devers, Brewster, & Casalino, 2003), where soaring rates of unin-surance make the attraction and retention of paying patients evermore important to the maintenance of the hospital’s fiscal health.

Nonetheless, medical anthropologists and sociologists haveexpressed concerns about the influence of consumerism onhealthcare (Clarke, Shim, Mamo, Fosket, & Fishman, 2003; Light,2000). Various stakeholders, from payers to managers, haveimported the culture and language of business into the hospital(Arndt & Bigelow, 2000; Fried, Deber, & Leatt, 1987). Hospitals nowroutinely market their care to individual patients, purchasers,research groups, lucrative patient cohorts, and international healthtourists (Baker & Lamb,1992; Ramírez de Arellano, 2007). Hospitalsincreasingly define themselves as producers of a product for anindividual consumer, not providers of essential services toa community (Beardwood et al., 1999). Administrators face newimperatives to maximize patient choice, measure and improvepatient satisfaction, and encourage patient complaints (Nettleton,1995). Without question, consumerism has altered the profes-sional identity of healthcare providers (Freidson, 1970) andhealthcare design (Kearns & Barnett, 1997). Consumerism has alsofueled the patient-centered movement. Because it defines thepatient as a rational subject who can be calculating in her choicesabout care (Lupton, 1997), consumerism provides patients with anoutlet for criticisms against the medical establishment and indi-vidual doctors (Potter & McKinlay, 2005; Starr, 1982). While theseconsumerist trends provide one perspective on the hospital designI will describe, the individuals we interviewed do not emphasizethe competitive marketplace as a factor in local interpretations ofpatient-centeredness. Instead, they discuss the impact of socialvalues on priorities and decision-making, even as consumeristdemands may be operative (Timmermans & Almeling, 2009).

For instance, as we will see, interviewees describe the hospitalas a designator and manager of boundaries: between patients andcaregivers, between illness and health, between the public and theprivate, and between substance and surface. Science and tech-nology scholars would discuss hospitals as machines that “simul-taneously embody and measure a set of relations betweenheterogeneous elements” (Akrich, 1992, p. 205), including socialactors, technical objects, states of being, and goals. Designerschoose the attributes of their objects, including hospitals, bymaking assumptions about the social world into which themachine will be introduced. While technologies impact physicalspace and the exigencies of medical work (Koenig, 1988; Wears &Berg, 2005), hypotheses about the social configuration of carealso drive technologies (de Laet & Mol, 2000; Timmermans & Berg,2003). Moreover, as Akrich (1992) argues, “technical objects andpeople are brought into being in a process of reciprocal definition inwhich objects are defined by subjects and subjects by objects” (p.

222). If so, then the interpretation of patient-centeredness used tobuild the machine of the hospital not only reflects social assump-tions but also could limit the possibilities for human action (Hess,1996).

Considering the hospital as a machine with a potent role inestablishing and enforcing boundaries provides one view of thecomplicated array of priorities and beliefs activated as hospitalsmake patient-centeredness material. If, in part, the moral value ofthe concept of patient-centeredness rests in its hope to empowerand engage patients by minimizing their figurative distance fromphysicians, it is critical to examine how the machine of the hospitalmay facilitate or counteract this value. Moreover, the play of powerappears deserving of consideration in such institutions, given whatmany have considered to be the historical role of the hospital inconstituting patients as docile bodies subject to the medical gaze(Foucault, 1973). And, as we will see, policies at the hospital westudied prioritize the production of a particular type of caregiver. Asthey do in other healthcare environments, administratorspromulgate policies that target provider behavior as valuableprimarily because of their moral e rather than their technical orscientific e content (Carr, 2009; Hopper, 2007). Because ideas ofpatient-centeredness circulate in this complex context, I lookbeyond a consumerist or managerialist explanation for the deci-sions made at the hospital we studied, highlighting instead theinterdependence of hospital design and concepts of the patient, theprovider, and notions of caring.

Setting and methods

The hospital is a newly built facility in a US urban setting thatprovides general medical and specialty care. The data come frominterviews conducted by the author and/or other research teammembers (SS, EO) between 2009 and 2010 with planners, admin-istrators, and designers of the new hospital. Interviews took placeat least one year after the opening of the hospital. Intervieweesincluded individuals who made critical decisions about hospitallayout and space allocation. The study team developed thepurposive sampling frame in collaboration with a senior adminis-trator at the hospital. Thirty-nine individuals were approached,yielding 35 participants: 4 senior administrators; 4 nursemanagers/administrators; three architects or designers; 9 hospitaltransition planners; and 15 administrators of hospital operations.Interviewees were asked to comment on the intent of the design, tosuggest how the hospital exceeded or failed to meet their expec-tations, and to describe their priorities for hospital care. They werefurther asked to discuss what they feel patients and staff need fromhospitals and to comment on specific features of the building andits amenities (i.e., private rooms, the hospital lobby). Whilesystematic participant observation was not conducted, supple-mental datawere gathered through personal communications (e.g.,hospital staff listservs, hospital documents provided by inter-viewees), through three go-along interviews with visitors (i.e.,family or friends of patients) who expressed an interest in theresearch (Kusenbach, 2003), and through online publications aboutthe hospital.

Interviews were audiotaped and transcribed; transcripts werechecked against the audio. Transcripts were anonymized andreturned to interviewees for editing; interviewees made onlya small number of minor changes. Study procedures were approvedby the institutional review board of the hospital. The author usedthematic content analysis to analyze transcripts as well as mediareports and published interviews with administrators (Ryan &Bernard, 2003). These latter documents were either available inthe public domain or were obtained from interviewees. Analysisbegan with open coding to search for themes with cross-cutting

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relevance. A set of codes was developed to designate emergentthemes, data were re-read and coded, then coded categories werecompared both within and across transcripts and triangulated withother data sources. Themes were thus refined and narrowedthrough iterative comparative coding. Final themes and conclu-sions were reviewed extensively with other members of the studyteam. They were also discussed with non-informant observers ofthe hospital and were then further refined to reflect the mostsalient and consistent features of the data.

Results

The hospital design process began more than a decade beforethe hospital opening when architects established the building’sfootprint. Architects, designers, and other decision-makers weinterviewed emphasize that, from the outset, they envisioneda tight link between the features of the building and a new cultureof care that would emerge within it. In interviews, they oftendescribe the structure itself as an actor in this process. Theseindividuals want an impressive and prestigious building and onewith the capacity to provide cutting-edge medical care; but theyalso want the building to project hope, healing, and human-ness.Like the patient-centeredness concept itself, they describe thebuilding as a corrective to the dehumanization and technicality ofcontemporary medicine. A lead architect says the new hospital,“embraces the idea that good architecture is an integral part of thehealing process,” creating, “an environment that is cheerful,inspirational and intimate, despite its large size.” He continues,“We’ve aimed to design an environment for people, not justmachines” (online internal news release, 6/4/07). Another leadarchitect says, “somehow the human scale should come in,”through the elimination of “long corridors and endlessly numberedrooms”; he sought to design a sense of “smallness” into the space(internal development video, 2007). This discourse of a humanisticbuilding were in keeping with various inspirational phrases useddescribe the new space and the work it facilitated, epitomized bywords of one of the hospital’s senior administrators: “Our vision isto heal humankind, one patient at a time, by improving health,alleviating suffering and delivering acts of kindness” (interview, 4/23/09).

Similarly, in describing the new space, another of the hospital’ssenior administrators acknowledges the importance of the qualityof the medical care delivered there, “But most importantly, whatmakes us get up everyday and every night to go to work is what ourpatients tell us. We are very, very patient-centered” (online inter-view, 10/12/10). These elevated visions set the tone for the concreteinitiatives put in place to operationalize patient-centeredness. Mostadministrators describe these initiatives as idealistic, proudlydisruptive, andmorally freighted. I will discuss three key features ofthe operationalization of patient-centeredness. First, plannersinstituted a thorough onstage/offstage approach to the materials ofmedical care, such that the tools of care delivery are hidden fromview. Second, they implemented a ‘concierge approach’ to thepatient that prioritizes the customer service tasks performed byhospital staff. Third, they implemented scripts for communicatingwith patients and families, teaching specific techniques for inter-acting that prioritize courtesy within the providerepatientrelationship.

Onstage/offstage

As one administrator says of the hospital, “it’s almost likea Disneyland. You have that certain way of the [hospital], and thenyou have in the background all the business that goes on in orderfor it to have [sic] a good experience when people come in. That

always continues to amaze me” (interview, 07/08/09). A leadplanner explains that the space of the hospital is divided intoonstage and offstage areas, consistent with “the Disneylandconcept” (interview, 5/5/09). These individuals’ links betweenDisneyland theme parks and this hospital’s architecture are nottrivializing comparisons but reflect a deeply serious intent of thedesign. The layouts of Disneyland theme parks are emulated fortheir ability to generate a seamless fantasy world. Disneyland parksuse onstage/offstage space partitioning to hide from visitors themachinery, human action, and infrastructure that make the parkfunction. These principles e centered on concealing from thevisiting public the techniques that constitute the work thatproduces or defines the setting e are increasingly important inhealthcare design (Less, 2004). For instance, the Disney Institute,a business consulting arm of the Disney corporation, has recentlyopened a healthcare consulting service to advise healthcaresettings on design principles andmanagerial strategies. By applyingthe Disneyland concept, hospital designers and planners aim tohide the work of the hospital from patients and visitors bysequestering staff, medical chores, and materials offstage. Thisparadigm structures numerous aspects of hospital design, from thelayout of units to the positioning of the elevators, entrances andexits; and it structures policies about allowable activities and careprocesses.

As a result, much of whatmakes the building a hospital is walledoff, including the technical, material, and interpersonal aspects ofcare provision. Treatment rooms, medical equipment and supplies,and space dedicated to staff are within a central core area on eachfloor, hidden behind heavy, unmarked, closed doors. Doors totreatment or testing rooms are also usually unmarked andwindowless so that passersby have no indication of thework takingplace inside. The clerical supplies and charts are situated behinda greeter’s stations so they are hidden from visitors on the unit. Nocarts or equipment sit in the hallway. The onstage areas, includinghallways, patient rooms, and open nursing units, are to be keptparticularly clean, without carts, supplies, or equipment (interview,5/5/09). As one administrator says admiringly (interview, 9/25/09),visitors see no “hospital type things, carts and junk.”

In fact, designers devoted significant floor space to ensure thatvisitors rarely see hospital equipment, such as the supply carts thisinterviewee mentions, anywhere. Large hallways and spaciouslobbies leave only about half of the square footage of the buildingassignable as patient care areas. Because onstage areas offer littleprivacy for staff, conversations between providers usually takeplace inside the central core, behind closed doors. This means thatthe hallways are often fairly depopulated, with staff spread out overan extensive amount of open space. Designers included almosttwice the usual number of elevators for a hospital of this size, with8 elevators for use only by the public and another 10 for movingpatients and supplies. Designers further differentiated public andstaff space in the hospital by installing different flooring in eacharea, with the more “economical” flooring indicating staff space(interview, 5/5/09). Administrators allow staff to use only certainentrances and exits, evenwhen this creates inefficiencies. The pathfrom the staff parking structure to the hospital leads directly to anentrance intended for families only, so administrators put signageup indicating, “this is not an entrance, it’s for family members”(interview, 5/5/09), and staff are required to take a longer route toenter the hospital.

The architects wanted the building to be dominated by featuresand referents outside of it. They maximized natural light in patientrooms with floor-to-ceiling windows. They organized hallways intopavilions that allow visitors to look onto a series of patios, foun-tains, and gardens. Most all units look identical, and all walls arebare and clean. Even the pediatrics floor, typically multicolored and

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embellished with murals with cartoon characters, is intentionallyundecorated. Posting onwalls is restricted to locked bulletin boardsavailable in offstage areas only. Designers did away with almost allsignage. As a result, visitors can have difficulty finding the Emer-gency Room or their hospital unit, but architects and designers feelthe lack of signage conveys a “really sturdy, elegant” look (inter-view, 6/23/10), as well as a more intimate and less institutional one.The lobby is grand and high-ceilinged, with awide staircase leadingto a lower floor. The first floor resembles a museum or theaterlobby, with extensive marble and sweeping curved lines.

Many designers, planners, and administrators describe a desirethat the building belie its function; they intend for it to look unlikea hospital. One planner says, “many people when they walk in theground floor they say they don’t feel like they’re in a hospital.thebeauty of the architecture, there’s nothing ‘hospital’ about it. It’sa grand space, the lobbies . the circular openings through thelower level, nothing says ‘hospital’ there.” He continues: “So I thinkthat’s the beginning of the healing environment” (interview, 5/5/09), as if a hospital-like environment would not be a place forhealing. A development officer who gives tours of the building saysthat visitors frequently exclaim happily, “God, I feel like I’m ina hotel. I don’t feel like I’m in a hospital” (interview, 10/1/09).Another administrator agrees: “It’s kind of hotel-ish looking”(interview, 6/14/10). It conveys, another says, “that just overallwarm feeling that you get when you’re not expecting to be ina hospital,” (interview, 4/27/09) or, as another echoes, “that kind ofwarm and fuzzy feeling” (interview, 6/26/09). One architect wantsto call the space “inviting,” but decides that might not be anappropriate descriptor for a hospital. Yet what does a hospital looklike? This is less often articulated, but one planner calls hospitals“sterile and unfriendly and cold” (interview, 5/5/09). Anotherdescribes herself as grateful that guests are not, “hit in theface.with patients who look ill” (interview, 10/1/09), as theypresumably would be in a hospital-like environment. Of course,these informants are aware that the hospital identity is hidden butnot erased; yet informants express a consistent enthusiasm aboutthe features that construct a non-hospital referent for the building.

Concierge

In addition to this anti-hospital approach to the design, the newhospital instituted customer service interventions transplantedfrom the hospitality industry. Because this principle “emanatesfrom the hotel industry” (interview, 04/23/09) and to emphasizethe rapid and responsive nature of the customer service that was tobe delivered, I call this second strategy used to build patient-centeredness the concierge theme of the hospital design. I alsouse the word concierge to highlight that the emphasis on customerservice is described not just as a change in the behavior of staff butin their professional roles, as articulated by one informant whoasks, “I’m confused. Am I a nurse or a concierge?” (interview,12/02/09). Private patient rooms, room service meals, and an emphasis onthe details of non-medical customer service are key aspects of theconcierge theme. The customer service tasks that this interventionfocuses on include welcoming family with coffee and chairs,offering amenities (e.g., extra pillows) for guests, and respondingpromptly to complaints of any type.

Administrators and designers describe these concierge featuresof the hospital as facilitative of a central aim of the redesign: to shiftthe culture of care delivery toward more thorough attention topatient and family comfort. A senior administrator, describing thebuilding as central to the actions of those within it, calls this effortat culture change “leveraging the move” (interview, 04/23/09). Themove, he says, is a “burning platform,” a business managementterm for an opportunity to purge the hospital of inhospitable

attitudes and habits. Specifically, he describes a vision of a newculture of healthcare modeled on the service industry, with thehealthcare worker improving the experience of hospitalization bymaximizing comfort and attending to guest requests. Anothersenior administrator also discusses this culture change in languagethat echoes the emphasis of the patient-centeredness concept onidentifying and then orienting care toward the patient’s expresseddesires: “I want there to be a permanent change in culture inwhichthe patient always is first and foremost and we recognize that it isa privilege for us to be serving them, and not the other way around”(online interview, Spring 2009).

Private patient rooms are a key feature of the design. Mostpatient rooms measure about 300 square feet in size. All have livingroom-style furniture, a private bathroom, television, satellite radio,wireless internet, ample storage space, and a daybed window seatso that family members can spend the night in the patient’s room.The hospital has no set visiting hours to encourage family to comeand go and to remain in the room for long periods. In addition, asdescribed by my informants, supervisors invest substantial time intraining staff to be quickly responsive to patient and family requests.Nurses and other staff are evaluated on the speed with which theyaddress patient and family needs. The new hospital also includesa new dress code and uniforms for all staff. A senior administratorexplains that “staff are in nice crisp uniforms,” like the admissionsclerks who wear blue suits and a white shirt, because “we can’t gointo this beautiful . building looking like slobs” (interview, 4/23/09). Finally, the hospital has neither a standard menu nor scheduledmealtimes. Meals are delivered by room service. The patient isprovided with a menu and calls to order whenever he or she wouldlike to eat. Servers in bow ties called “ambassadors” (interview, 04/23/09) deliver meals. An administrator calls this the “5-star hotelkind of concept” (interview, 4/28/09).

Training procedures teach nurses to address complaints andoffer comfort measures to family members as they arrive. Super-visors emphasize the importance of anticipating needs, as onenurse manager says, for “If we could foresee what [the patientsneeds], then theywouldn’t have to press the [nurse call] button.Wewant to catch those things before you leave the room, check if theyneed anything else, rather than you walk out of the room, and theyrealize they don’t have ice water” (interview, 12/5/09). The cheer-fulness of nurses’ responses to these requests is also described asimportant. Another nurse manager says, “usually when you pressthat call button the nurse comes in and kind of goes, ‘What do youwant?’ instead of with a smile, ‘Hey, how can I help you?’ That goesa long way” (interview, 10/1/09). The job of the food service staff“changed dramatically,” as well, according to a manager of thehospital’s nutrition service, for “[n]ow their role is customerservice,” rather than managing dietary rules: “You need to besparkly and friendly” (interview, 4/28/09). The ambassadors whobring meals are trained to attend to the patient’s little likes anddislikes, for example, “I like this cold or this hot or I like my food tobe like this” (interview, 4/28/09).

Finally, administrators revised recruitment procedures to bringon staff aligned with this emphasis on customer service. Thehospital models its approach on the Ritz Carlton (Hotel Chain)customer service philosophy, whereby staff receive extensivetraining to address every complaint thoroughly and immediately(Berry et al., 1994). New applicants for hospital positions, includingnurses and physicians, complete an online behavioral assessmentdeveloped by Ritz Carlton called Talent Plus that includes questionsabout attitudes and inclinations, such as “Can you smile everyday atevery single personwho comes into the hospital?” and “Can you bepolite to 100% of those you come in contact with?” Those who pass(only about 50% do) undergo a 45-min behavioral interview(interview, 4/23/09). As a senior administrator describes it, the

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hospital used to hire those with the best training and technicalproficiency, but now the aim is to hire those who are also best atdelivering “compassion” (online interview, 10/12/10) throughexcellent customer service.

Scripting communication

Finally, policies in the new hospital environment focus consid-erable attention on communication between staff and patients andvisitors. As informants describe it, the focus on improving commu-nication is not pursued in a general way, but through a specificintervention called the patient courtesy initiative that applies tonurses, physicians, and all other staff in the hospital. The strategyaddresses the structure and content of communication by teachingstaff a sequence of steps to follow in interacting. Many informantsdescribe this courtesy initiative as the cornerstone of the hospital’spatient-centered approach. As one says, “it has been a constantpush, from my perspective, and everybody’s responsibility acrossthe board” (interview, 12/5/09). Six components of the interactionare outlined: first, theway to enter a room, to address the patient (byhis or her last name), and to ask permission before sitting down atthe bedside; second, the components of an introduction to includeat each encounter, including one’s name and role in the patient’scare; third, the task of conveying information to the patient; fourth,the need to ask permission of the patient before proceeding, such asbefore sharing information or conducting a physical exam; fifth, thetask of responding with a sense of urgency to patient needs; andsixth, theway to exit courteously by informing the patientwhenyouwill return and what will come next.

An administrator describes this initiative by comparing it toa neighboring hospital’s emphasis on courteousness. In contrast,she says, “we have. cards,” that state the acronym for the steps ofthe interaction. Staff hang these cards under their badges, and theacronym is displayed throughout the hospital on stand-up displaysand posters. The policies do not literally script interactions, but, asone administrator explains, this acronym for structuring theunfolding features of the interaction is key to the initiative’scapacity to pervade the work at every level of the hospital: “wemake sure that we ask you those questions, did the person call youby your name, did they introduce themselves, did they communi-cate, did they ask you if you have any others questions, did theyrespond. So I think it’s more of a script. I think everyone canpractice it and maybe kind of bring it home for every level and forevery service you can provide” (interview 5/11/09). As another says,“we have very specific things, and they even have it posted, whatthey’re supposed to say, and they have scripts, and to be pleasant,have a smile in your voice, and how to handle peoplewho are upset,and things like that” (interview, 4/28/09).

These communication techniques are also taught to physiciansas key to effective doctorepatient interaction as providing the,“details and techniques of patient communication,” and the tools,“for effective patient-centered communication” (online trainingvideo, 2010). The video recommends supplementing the steps ofthe communication with other techniques, like looking the patientin the eye, leaving a business card, and giving options for contactingproviders. The video advises doctors to repeat themselves andexplain who will be covering when the physician is away. Thetraining provides some brief instructions about maintaininga beneficial emotional tenor in an interaction. The physician in thevideo suggests that patients can feel abandoned by their doctorswhen a doctor unknown to the patient arrives to cover their care forthe day. And, he says that in addition to an appropriate introduc-tion, “the other thing they need from their physician is some senseof hope. They want their physician to be realistic, but they don’twant to be written off” (online training video, 2010).

The specificity of the steps in the initiative facilitates both itsimplementation and efforts to monitor its performance. Adminis-trators and supervisors teach this initiative to all staff throughtrainings, small group meetings, and supervision. An administratordescribes how feedback from visitors is gathered, tracked ina database, and shared extensively with others at staff meetings.Administrators place evaluation cards and drop boxes throughoutthe hospital, asking visitors to rate staff on their use of the steps ofthe acronym. Managers audit feedback twice a month in order toassess how often their staff follow the steps of the initiative, andtheir supervisors encourage managers to reward staff who scorehigh with nominal gifts such as movie tickets (interview, 5/11/09).Another administrator describes the effectiveness of the moni-toring practices: “We have developed models where every patientinteraction is modeled.. [I]f you’re a manager, all of youremployees are in there and you can go in and score them, then youhave a score ratings one to three, and you might have 15 attributes,like do you knock on the door every time you go in, those types ofthings” (interview, 4/3/09). Managers further ask nurses to monitorone another on the performance of the components of the initiative(online interview, 10/12/10). With an unusually robust reproach ofmost nurses’ usual demeanor, one administrator calls the initiativea mission to “attack that nurse’s attitudinal behavior at the point ofpatient care” (interview, 4/3/09).

Discussion

In its consistent application of onstage/offstage policies, itsintense focus on customer service, and its efforts to direct thecontent and structure of patient interactions, this hospital repre-sents a specific interpretation and implementation of patient-centeredness. Nonetheless, the choices made at this hospitalreflect trends in hospital design across and beyond the UnitedStates today (Altimier, 2004; Collins, 2007; Goldman et al., 2010;Kearns, Barnett, & Newman, 2003). Like this hospital, a newhospital in the UK is said to look more like “a hotel, a trendy bar,”than a healthcare facility (Gesler, Bell, Curtis, Hubbard, & Francis,2004). While many of these changes seem to reflect the influenceof managerialism and consumerism on healthcare, for those Istudied, the social and moral values embedded in these designs aremeaningful in themselves. One planner, agreeing that manyhospitals are moving in this direction, describes a neighboringfacility:

I was pretty impressed. It looks like you’re in a country club. It’sjust that idea of steering away from institutional and sterile andvisiting hours and quiet.It’s just very welcoming, it’s warm,and I think it gives people hope. And having hope for familymembers and patients makes your job a lot easier. So I think itmakes you very proud to be part of it (interview, 5/5/09).

Here, he desires a corrective to the dehumanization he perceivesin contemporary medicine, and he views hospitals that resemblehospitable settings as effective solutions to the alienation of careprovision. In this way, he echoes the enthusiasm for the concept ofpatient-centeredness and indicates the concept’s flexibility incontaining an array of aspirations. It is notable that most infor-mants describe these types of design choices as unquestionablysuperior to alternatives and uniformly better for patients. Or, as oneof the senior administrators at this hospital says to explain theirchoices, “There’s no one more important than the patient” (onlineinterview, 11/23/10). Our study aims to understand the assump-tions about care and patients that these trends indicate.

Indeed, data from patients suggest preferences for homelikeenvironments with views of nature and natural light (Curtis et al.,2007), an absence of long corridors, private space, and elements

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that promote a sense of normalcy (Douglas & Douglas, 2005). Someof these features have been hypothesized to improve recovery(Ulrich, 1984), and private patient rooms may offer advantages ininfection control (Ben-Abraham et al., 2002). However, data onthese issues are both limited and mixed (Dettenkofer et al., 2004;van de Glind, de Roode, & Goossensen, 2007), and an environ-ment perceived as healing by one individual may be perceived asunpleasant or outright harmful by another (Laws, 2009; Williams,2007). Moreover, while measures of patient satisfaction areincreasingly used to evaluate the impact of these changes, thesemeasures have limitations, including confounding by patientcharacteristics (Atkinson & Medeiros, 2009; Glick, 2009; Hekkert,Cihangir, Kleefstra, van den Berg, & Kool, 2009; Findik, Unsar, &Sut, 2010; Thompson & Sunol, 1995) and a weak relationship tothe technical quality of care (Stolzmann et al., 2010). This paperdoes not report on the impact of this space on patient and staffexperience but instead describes the intentions made manifest inthe design in order to consider the implications of implementationsof patient-centeredness. The choices made at this hospital fore-ground questions for further study, including: What impact doonstage/offstage practices have on the safety, quality, and timeli-ness of medical interventions? Does providing a script for thecomponents of interactions ease communication betweenproviders and patients, and what aspects of providerepatientcommunication (e.g., information exchange, perceptions ofempathy) change as a result? What kinds of design features andhospital policies make patients feel more engaged in their care ormake them feel more hopeful, as the planner quoted abovesuggests? And, crucially, how do hospital staff experience thesechanges? Here I focus on three questions raised by the datareviewed here.

(1) The status of professional expertise in patient-centered environ-ments: Administrators and designers suggest that the notion ofpatient-centeredness may have altered their views of theobligations and proficiencies required of healthcare profes-sionals. As described above, one administrator says that the jobdescription of her employees has moved away from a need forexpert knowledge (in part because computerized databasesnow assist them with some tasks) and “[n]ow their role iscustomer service” (interview, 4/28/09). And, hiring practicesthat used to focus primarily on hiring those with the besttraining and technical skill now aim to hire those who are alsobest at delivering “compassion” (online interview, 10/12/10).These choices do not necessarily indicate that expertise is lesscentral to the definition of a medical professional as service orcourtesy become more important. Yet, combined with otherfeatures of the implementation of patient-centeredness, thesedata may suggest medical professionals’ understanding of theirwork could shift in settings like these.For instance, by prioritizing an orientation toward the indi-

vidual patient, this operationalization of patient-centerednessseems to physically orient providers away from one another.Computers are placed in rooms so that nurses can enterinformation in the patient’s chart while staying at the bedside.Architects built few conference rooms and lounges, leavinglittle room for physicians and nurses to congregate. Inexplaining how to operationalize a focus on the patient, someinformants say that staff should spend less time talkingamongst themselves and more time talking to patients. Or, asone architect explains the assumption, with the aid of tech-nologies, “in the future, nurses will just need to pass through[the nurses’ station]; communication occurs with the patientonly” (interview, 6/23/10). Some even describe staff collegialityas a threat to hospital performance. One describes efforts to

discourage staff from chatting with one another. In response,some nurses say, “they don’t feel this close-knit community,”but the administrator explains that staff tend to, “think moreabout their own personal needs than what is best for thepatient” (interview,10/1/09). This suggests that these designersand administrators may be underestimating the importance ofstaff communication. Studies consistently show that an effec-tive sociotechnical network and the empowerment ofproviders are central ingredients in hospital work (Curry et al.,2011; Hewett, Watson, Gallois, Ward, & Leggett, 2009). Thisliterature indicates that providers must also talk to one anothercontinuously to pursue and maintain a quest for safety andquality (Provonost & Vohr, 2010); yet space may not be struc-tured to support this in this hospital. As one planner says, “yourinterprofessional relationships, I think, are harder in that kindof a space” (interview, 7/23/09).In addition, discussions of the technical content of medical

care and the ways in which the design would facilitate it wereoften absent from interviews. Some informants describe theirinvolvement in training drills called patient tracers (in whichtransitions in patient care are practiced), in exercises to allowstaff to test the functionality of the new space, or in efforts tosee that equipment functioned well the moment the hospitalopened. Only two of our informants focus on issues of technicalquality, including managing equipment and workflow in theoperating room and infection control. Of course, other infor-mants are aware e and sometimes explicitly mention e thatmuch of the safety and quality of the medical care in thehospital rests on the proper performance of complex tasks suchas changing IVs and central lines; tracking and administeringmedication; or coordinating a treatment plan with otherproviders, the family, and patients. The new environmentbrings numerous changes to the performance of these tasks.Nonetheless, even when these tasks are mentioned, mostinformants’ discussions of the new hospital focus at length onthe ways in which the new environment facilitates impeccableattention to customer service work. As one nurse administratorsays, “we know this isn’t a hotel, we know it’s a hospital, butwhat we’re really trying to do is step that up and do those littleextra special things” (interview, 4/27/09). While I am sug-gesting that this aspect of the data may indicate a substantiveshift in emphasis in this interpretation of patient-centeredness,other explanations are possible. Informants may reasonablyassume that the quality of the care in the hospital is exceed-ingly high. The pattern in the data may also be partly attrib-utable to the structure of the interview or to sampling choices.

(2) Concepts of care in patient-centered environments: Despiteconsiderable attention to patient and visitor comfort in thisinterpretation of patient-centeredness, it is not clear from theirinterviews how informants conceptualize the caring work thattakes place there. Unlike many of the nurses we interviewed,these informants provide few details of the complex interper-sonal and temporal acts of caring that take place in hospitalsettings (Mattingly, 2010). Risse (1999) describes the hospitalas a “house of crises and rituals,” employing this rubric tointerpret, “the choreography of institutional routines,” as wellas, “the experience of hospitalization for patients” (p. 10). Hedescribes hospital practices that can embody “the traditionalhospitalitas or gift relationship between caregivers andpatients” (p. 664). Mol (2008) discusses how “the good” ofcaring becomes manifest “in practice” in heterogeneous,particular ways shaped by the unique and unfolding position ofthe patient; she labels this morality in action (p. 74). Mattingly(1998) discusses our relationship with “that essential humanexperience e devastating, life-altering illness,” as an indicator

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of, “how a culture conceives life in time, being as a kind ofbecoming marked by transitions, transformations and theinexorable progress toward death” (p. 1).

Some of the design features present a different image ofcaring. The onstage/offstage policies sequester supplies withincores of the units, and patients are spread across large units inprivate rooms. For staff, these features lead to a good deal ofwalking back and forth from staff areas to individual patients’rooms. Policies emphasize timeliness, intense responsiveness,neatness, and consistency in care, such as that staff are trainedto follow all steps of the patient courtesy initiative in everyencounter. Service is equated with compassion in the instruc-tion in the initiative that staff are expected to respond “topatient and family needs with a sense of urgency andcompassion.” As informants discuss the experience forpatients, most are pleased that the environment is “verypleasing and comfortable” (interview, 12/5/09), and theydescribe the patient experience as positive as a result of “whatour employees are doing to make people happy everyday andtaking [sic] care of their needs” (interview, 4/16/09). These datatogether could suggest that compassion has been conceptual-ized as a concrete product delivered, as if to-order, by anindividual whose special expertise is exemplary service.

In other ways, the design may reflect an acquiescence toinstrumentality in the providerepatient relationship. If thehiring practices reflect standards used by the hotel industry,the relationships encouraged may also reflect the routinizationof relationships characteristic of the service industry (Leidner,1993). Modeling patient communication as a sequence ofquestions and behaviors may facilitate implementation of thepatient courtesy initiative, but it may also construct theproviderepatient relationship as a fleeting transaction ofproduct provision, like the transaction between a cabbie andhis fare (Potter & McKinlay, 2005). Or, the initiative mayfunction primarily as a managerial technique in which inter-actions are mechanized in order that they be controlled andpoliced (Foucault, 1991). Acquiescence to instrumentality inproviderepatient relationships may also be reflected in the factthat training in the patient courtesy initiative fulfills nationalrequirements for medical resident curricula in both profes-sionalism and interpersonal communication (administrator,personal communication, 12/20/09). Finally, the overallemphasis on demarcating and controlling boundaries betweenvisitors and staff may widen rather than narrow the literal andfigurative distance between providers and patients, suggestingthat it may be precisely providerepatient relatedness that isjeopardized in this patient-centered environment.

At the same time, such extensive attention to the problem ofproviderepatient communication, the centrality of compas-sion, and what one nurse calls “the aura of optimism” thebuilding conveys (interview, 10/15/09) may effect a range ofbeneficial changes, including in patient empowerment, asadvocates of consumerism argue (Starr, 1982). In the absence ofunlimited resources or structural changes [such as equitablecompensation for patient counseling (Pear, 2011)] that coulddramatically alter the conditions for relatedness amongproviders and patients, interventions like the patient courtesyinitiative may, at the very least, forcefully demonstrate insti-tutional commitment to the importance of communication inthe hospital. Moreso, the repeated practice of knocking beforeentering, sitting down at the bedside, and looking the patientin the eye (as the initiative recommends) may bring aboutunbidden changes in the providers’ emotional and cognitiveexperience of the encounter, as techniques of the body may do(Mauss, 1973; Wacquant, 2004). For instance, one planner, who

was not involved in the patient courtesy initiative, felt pleasedthat, “they were really working on the softer side of the orga-nization, and I think knowing that was going on was reallygood” (interview, 6/29/09). In short, it would be important tounderstand more about how such initiatives may or may notimprove the interpersonal context of caretaking; and whetherand in what ways these initiatives might encourage providersto learn and practice the intricate communication skillsinvolved in caring for vulnerable patients (Sox, 2002; Swick,2000).

(3) Perceptions of patienthood in patient-centered environments: Afinal question can be raised about the implications of concealingfrom patients the work of medical care. Specifically, manyinformants report that patients prefer not to see thework of thehospital, and administrators and designers devote substantialresources e including space, expensive materials, and efforts toimplement policies for staff movement e to instituting thisprinciple. These features may construct the patient in thesesettings as best kept away from the ugliness, technicality, oruncertainty of illness and its treatment; or, they could inculcatea view of patients as uninterested, unwilling, or unable toconfront the realities of hospital care. The setting could seem toprioritize efforts to obscure from the patient the powerfulintrusion on the self and security that is the reality of a hospitalstay. Indeed, some planners describe the design as servinga fantastical aim: concealing from patients and visitors the factthat they are in a hospital at all. These trends bring to mind theanalysis by Evans, Crooks, and Kingsbury (2009) of the wide-spread display of landscape paintings in healthcare settings.They argue that such art can be seen as providing a benevolentdistraction from the frightening reality of illness; or, it can beseen as an abstraction of the medical gaze that prepares thepatient for subjection to the power relations at play in medicalsettings. In other words, aesthetic decisions can soothe, andthey can also encourage the patient to cede control. These issuesare important to explore given that patient-centeredness isfrequently promulgated and perceived as a strategy forengaging patients more fully in their care (Berwick, 2009).

Relatedly, it is notable that, for planners, designers, andadministrators in this hospital, the concept of patient-centerednessdraws attention to the static frame inwhich care happens (from thesteps of interactions to the partitions that separate staff from visi-tors) as well as to aesthetic aspects of that frame (from uniforms toceiling heights). One administrator suggests that, in this hospital,attention to the form of care may have trumped attention toprocess:

I think in some respects too much was devoted to the ambi-ance or the appearance of the hospital. So in some respects Ithink that they lost track of the functional piece. So thearchitects or the interior designers came in with what they felta patient needed in order to speed up their recovery or maketheir visit better. And in some respects, as an observer onlybecause I wasn’t involved in that, I just kind of felt thatsometimes they made some decisions that were more based onthe aesthetics of the building versus the functionality (inter-view, 6/26/09).

Another (interview, 7/23/09) is more blunt: “Somebody had tothink about that flow [of work processes] at the beginning, and Idon’t think that happened. I think it really got built with . ‘whatwould look good?’ and then we’re all really good people and we’llwork around it.” These informants echo the debates about formversus process and surface versus depth that pervade the scholar-ship on patient-centeredness (Mead & Bower, 2000; Zandbelt et al.,

E. Bromley / Social Science & Medicine 75 (2012) 1057e1066 1065

2006). That is, to put it simply, patient-centeredness can be viewedas a set of attributes and principles to guide practice (Krupat et al.,2001; Langewitz et al., 1998) or it can be seen to emerge in the co-construction of care that takes place in particular healthcaresettings (Holmstrom & Roing, 2010; Mayes, 2009). As these infor-mants indicate, decisions about form in this hospital sendsubstantive messages about priorities, power relations, and moralvalues. And, in its emphasis on hiding medical work, striving to beunlike a hospital, and prioritizing customer service, the interpre-tation of patient-centeredness that this hospital embodies bothreflects and reinforces particular concepts of patients and care ofthe sick. It is important to explore, in rich detail, the consequencesof the changes that result as patient-centeredness moves fromtheory to practice.

Acknowledgments

This study was funded by the UniHealth Foundation. An earlierversion of this paper was presented to the American Anthropo-logical Association annual meeting November 2010 in NewOrleans,LA. The author wishes to thank Lisa Mikesell, Marian Katz, SusanStockdale, Joseph Mango, Elizabeth O’Toole, Stefan Timmermans,Kenneth B. Wells, PeterWhybrow, Joel T. Braslow, Neil Wenger, andJames B. Atkinson for invaluable contributions to this research. Theauthor also gratefully acknowledges anonymous reviewers for theirinsightful comments.

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