It was a long time ago, but I remember the details very well. I was a third year medical student on one of my very first clinical rotations (not that it matters, but it was my general surgery rotation). I was about a week into a rotation on the Pediatric Surgery service. Rounds started very early, and I had completed all of my pre-rounds (the rounds before the rounds - don't ask) on all of my patients, except one. The patient's mother told me that she had been admitted to the hospital very late the night before, and she had asked me if I could come back in another hour or so and let her daughter sleep. She was a post-op appendectomy patient who was otherwise doing quite well, so I told the mother that I would respect her wishes. During the rounds, the pediatric surgery fellow questioned why I hadn't examined the patient prior to rounds. When I told him about the mother's request, he became annoyed and replied, "This is a hospital not a hotel. Next time go in and examine the patient."
I have often thought about this specific case. Even now, almost 30 years later, I don't know who was right in this case. Would it have been all that bad to let my patient sleep for another hour? After all, rest leads to recovery. On the other hand, I was going to be in the operating room later that morning, and chances are that I wouldn't have been able to examine her until late morning. So I can certainly see the surgery fellow's side too. Now, as an attending physician, I would have just made the effort to come back later. Let the patient sleep! I still think that is the best approach, but I am not 100% certain.
As it turns out, if you ask the patients and families, they would prefer that hospitals would be more like hotels. Dana Goldman and John Romley at the RAND corporation published a study for the National Bureau of Economic Research (NBER) in 2008 entitled "Hospitals as Hotels: The Role of Patient Amenities in Hospital Demand". They later published an editorial piece about their study in the New England Journal of Medicine. What they found may surprise you!
Goldman and Romley surveyed several local hospitals in the Los Angeles, California market on patient amenities (which they defined as "good food, attentive staff, and pleasant surroundings"). They used a national survey to rate each of the 117 hospitals in the local market based upon their hospital amenities (households were asked to rate individual hospitals on whether it was their first choice based upon the hospital accomodations and amenities). Similarly, they used each hospital's mortality rate from community-acquired pneumonia as their marker of the quality of care.
The study involved almost 9,000 Medicare patients (so that hospital price was not a factor in the choice of hospital) who presented to one of the 117 hospitals for treatment of pneumonia. Patients under 65 years of age were excluded. When hospital amenities improved by one standard deviation, the demand for that hospital increased by close to 40%. The impact of amenities was smaller at hospitals that were farther away, so clearly patients prefer to be admitted to hospitals that are closer to home. A similar one standard deviation improvement in pneumonia mortality improved hospital demand as well, but only by 12%.
There are several factors that impact patients' selection of a hospital. Certainly one factor is proximity to where they live, as suggested by this study. It's also important that a particular hospital accepts a patient's health insurance, though that was not a factor in the current study, given that all of the patients were on Medicare. We can hope that patients select hospitals based upon the quality of care delivered there. While quality of care does appear to be a factor, it's by no means the most important. At least in this study, the hospital's amenities were more important than the quality of care delivered.
So, what does all of this say about whether hospitals should be like hotels? Well, I would draw the conclusion that the patient and family experience at a hospital is incredibly important. A recently published systematic review in the Journal of Healthcare Management establishes a definite business case for improving the patient and family experience. The authors of this review found that patients were more likely to return to the same hospital or ambulatory clinic if they had a positive experience.
Perhaps I was right to wait to examine my patient as a third-year medical student? Regardless, it's clear that quality of care is just one factor in attracting patients, and unfortunately it may not even be the most important factor. Hospitals should focus on trying to improve their patient and family experience scores, and one way to do that may be to evaluate the quality of their accomodations and amenities. To that end, maybe there is something that we can learn from the hotel industry?
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