Kennedy, David W. MD; Kagan, Sarah H. PhD, RN; Abramson, Kelly Brennen RN, MSN; Boberick, Cheryl RN; Kaiser, Larry R. MD
Amenities inpatient units that employ luxury hotel-style hospitality features at an additional cost are quickly becoming a popular service venture for many hospitals as marketing and revenue opportunities. However, these units are often undertaken as a business opportunity without the benefit of academically appropriate models. Such units lack the ability to address concerns about inequitable care or about potentially unethical differential access to care between patients in the amenities unit and in other areas of the hospital. Typically, these units offer hotel-style ambience with upgraded linens, a unit chef, business and family lounges, enhanced privacy and security, and superior service standards—amenities frequently not present in academic medical centers (AMCs). A lack of peer-reviewed literature about amenities units may be a factor in limiting the widespread development of these units in AMCs. Industry marketing information and some editorial literature is primarily focused on the related topic of concierge or boutique primary care medicine in private or group practice and offers minimal information or support for those developing such inpatient units.1–4 Consequently, inpatient amenities units may emerge in the marketplace, risking the perception of their placement in academic health care as anomalous, with confusion about their placement and role for medical faculty and students, and polarization among supporters and detractors, whose arguments suffer without adequate evidence.
At the University of Pennsylvania Health System, we undertook development of a 10-bed amenities unit as part of a patient-service facilitation program within a 695-bed AMC using a clearly defined and agreed-upon model. The model was developed by an interdisciplinary group of academic, hospital, and nursing leadership and was led by the physician medical directors for the proposed unit. In addition to broad interdisciplinary senior leadership, other key principles for our amenities model were the integration of academic values, service excellence, and recalibrated occupancy expectations, which take into account the multiple revenue streams that these units develop. Once we had defined our model, we employed the model throughout development of the unit to ensure its congruence with the values of academic medicine. These values were core to the physician faculty leading the unit and to the faculty who would admit patients to the amenities unit. The academic values identified for integration into the model included a consistent level of health care across the entire hospital with integration of teaching and clinical research on the amenities unit, as well as cognizance of the benefits obtained from philanthropic funds in advancing health care and research. Additionally, stakeholders recognized that this unit allows them to evaluate pilots of key service opportunities and to identify elements for improvement across the system.
The proposed model and the underlying principles that would govern the unit were carefully discussed with clinical departmental leadership at regular intervals during the planning process. Initial faculty feedback offered concerns that the unit would provide a different level of medical care compared with other units at our AMC, or that similar units at other institutions provided excellent amenities but inferior nursing and patient care. In this article we explore the model used to guide the development and operational aspects of our amenities unit, after reviewing applicable literature and detailing the institutional background. We outline steps taken to address faculty concerns, and implications for other AMCs that have or are considering an amenities unit close the discussion. Finally, we describe the measures we will use to evaluate project success on an ongoing basis.
The scholarly literature that directly addresses amenities units in academic or community hospitals is limited. Relevant literature exists in three distinct areas. The first is that of concierge primary care medicine practices. Such closed-panel practices typically offer expedited health care access and comprehensive medical services to a limited number of patients who pay a significant annual fee. Whereas some industry publications indexed in Medline argue for and detail the setup of concierge practices, most authors address the ethical dilemmas presented by such practices in light of many patients’ lack of health coverage and the reality of tiered health care and inadequate access.1–7 Although some ethical concerns regarding access to health care may be of interest in considering amenities units, these units differ from concierge primary care in that hospitals do not require that all admitted patients assume the added costs associated with these units; rather, they offer amenities units as an option separate from hospital admission.
The second area of focus in the related literature is service quality on inpatient units. Health care quality is understood in terms of well-established metrics as both Brindis and Spertus8 and Weingart et al9 point out. Weingart and colleagues note importantly that service quality is not well measured or understood and that it is generally evaluated only by patient interviews and self-report through service quality and satisfaction surveys. Their findings regarding service quality on a medical unit reveal a high frequency of service quality incidents, and they note that these deficiencies are associated with patient dissatisfaction with hospitalization. Almost 40% of patients in Weingart and colleagues’ study experienced service quality incidents, most commonly waits and delays, communication problems, environmental issues, and unsatisfactory amenities. Addressing service quality is a persistent and unmet challenge for hospitals nationwide and one that arguably requires innovative, bellwether models for solution.
Finally, there is literature that suggests specialized units are capable of meeting service and even educational needs with care that is delivered in different ways. The Planetree Model is the most studied and cited specialized patient-care unit of this type.10,11 Through a focus on personalized care and patient involvement that first gained prominence in the 1970s, the Planetree Foundation supported home-style units in several hospitals. Of these, the home-style unit at the California Pacific Medical Center–Pacific Campus was most intensively studied. There are marked similarities between home-style care and hotel-style care. The comforts of home and patient involvement are, however, less controversial in the context of hospital inpatient services than are the luxury of hotels and the services of staff, like concierges, not typically associated with health care.
Historically, when notable individuals (e.g., an employee of the university or a prominent political, philanthropic, or social figure) were admitted to our AMC, our experience of caring for these individuals was similar to that of many hospitals. Admission of these individuals required diversion of resources to create the privacy, comfort, and ease similar to what, Demaria3 argues, most physicians in America also enjoy as their own version of concierge care. In these cases, admitting physicians were generally those primary care physicians in whom such high-profile individuals place their trust for this type of care. Admission to the hospital then entailed that hospital administration, the admitting physician, and nurses hand-select resident teams, nurses, the hospital room, and other services to create a sense of amenities that met what are now known as “VIP-level” expectations. Fundamentally, however, in the absence of widely available hotel-style amenities, including linens, food, and a concierge to address requests not related to health care, the amenities offered to these individuals created a differential level of care. Addressing the needs of these individuals resulted in a de facto tiered system of care that was logistically difficult and ethically arguable.
Institutional response to change this de facto tiered system of care began with a vision of equal medical care for all inpatients, as well as an optional amenities model that would generate service excellence and patient revenue. Once created, such a model should, in the broadest sense, benefit all patients served by the hospital, as a result of an ongoing investment in the academic precept of best practices. It was immediately obvious that offering an amenities unit would relieve staff of creating a second tier of VIP care while redirecting the issue of patient amenities to a fee-structured option. Review of market competition quickly revealed the presence of amenities units in a number of other AMCs and cast our own development of such a unit as a market-savvy move. Contemplation of the academic medicine vision, commitment from a former patient familiar with amenities units as a primary donor, and analysis of the academic and philanthropic possibilities posed by such a unit generated our decision to open an inpatient amenities unit that would provide the same academic health care to all patients and a separate, fee-structured menu of amenities available by choice and payment.
In the summer of 2005, we appointed a steering committee composed of physician and nursing leaders, senior administrative representatives, and donors who had either been patients or whose families had previously been patients in the hospital. The committee was cochaired by the chair of the department of surgery and the vice dean for professional services, and it included the administrative director of the program, the department chairs of medicine, radiology, and emergency medicine, the director of the cancer center, the chief nursing officer, the unit nurse manager, the hospital chief operating officer, the senior vice president for corporate administration, and the clinical practice business administrators for medicine and surgery. Subsequently, as additional patient donors became advocates for the model, a limited number of additional external members were added to the committee. Developing a successful model and unit required, most fundamentally, involvement of physicians whose stature garners endorsement of faculty colleagues and whose personal ethics would engage those with a priori ethical concerns. Finally, the interdisciplinary nature of the amenities model mandated careful selection of administrative and nursing leadership who would collaborate with the physician directors. The roles of administrative director, nurse manager, and clinical nurse specialist would require superior leadership skills, clinical and systems expertise (as determined by the specific role), exceptional interpersonal skills, and compatibility with the medical codirectors. Since the unit opened in January 2007, the committee has remained as an oversight and improvement committee for the unit operations.
We initiated a communication plan so that the concepts of academic value integration, broad interdisciplinary leadership, service excellence, and recalibration of occupancy expectations based on multiple revenue streams were repeatedly presented broadly to clinical department chairs, faculty, and nurses. The plan emphasized the concept of a single level of medical care, and the potential for access by all patients, with the exception of those patients requiring critical or maternal–fetal care, whose nursing and medical care needs were considered too specialized for the unit. During the time the model was being developed, the communication plan included multiple written articles in newsletters as well as PowerPoint presentations which incorporated adequate time for discussion of the principles, at physician and nursing leadership meetings. The fundamental principle of providing one level of patient care institution-wide with amenities available to all patients at extra cost was clearly articulated during the communication process, and the related concepts were further refined based on input received from these presentations.
We drafted and validated a business plan to complement the clinical program. Developing the plan involved carefully reviewing inpatient amenities units at other institutions, validating with patient donors the need for and prioritization of services to be provided, and evaluating revenue streams, including the additional charges for the unit, occupancy expectations, and estimation of enhanced philanthropic donations. The oversight committee, senior health system leadership, and medical center development team all reviewed and endorsed the plan.
Our academic medicine amenities model uses four principles to achieve the aims of an amenities unit while upholding ideas valued in academic medicine. The principles are academically appropriate health care, broad interdisciplinary leadership, service excellence, and recalibrated occupancy expectations based on multiple revenue streams. Although some of the principles are strategic and some are largely operational, each of the four principles is linked to the others and is essential to the success of the academic model. Further, each principle has corollary elements that support its utility within the model.
Academic health care
Visionary response to our historical institutional experience mandated ensuring the same model of health care for all patients across the AMC. This principle was enacted with parallel articulation of the accessibility of the amenities menu to all patients. The academically appropriate amenities unit model we envisioned included teaching and clinical research participation on the unit. Accordingly, both residents and medical students participate on inpatient care and rounding on the unit, and patients on the unit participate in therapeutic research protocols. For instance, patients on the unit participate in chemotherapy research protocols, as they would on the dedicated oncology floors. The model also clearly recognizes the importance of philanthropy to the advancement of academic medicine and patient care, particularly in the current research funding environment. Finally, there is recognition that this unit serves as a pilot for identifying and improving service issues across the system.
Whereas some donors initially argued for services that would create a de facto different level of health care on the amenities unit, the necessity and fundamental principle of providing the same level of health care throughout the hospital prevailed and was accepted, thereby allowing the current concepts for the unit to be defined and the appropriate amenities identified. Accessibility of amenities was predicated on developing a program that would allow any patient to opt for hotel-style amenities with the choice to spend his or her personal financial resources—most often conceived as discretionary income—for the amenities package. A clear fee structure applied to all patients utilizing the unit, prominent local and in-house program advertising, and offering the program at preadmission without apprehension—or misapprehension—of any particular family’s financial resources were critical to overcoming ethical challenges. These characteristics also optimize teaching experiences that express the value of providing the same academic health care and equal access to it apart from the amenities package. We took the position that, particularly to achieve congruence with values of academic medicine and to break the Gordian knot of two different levels of health care, providing the same level of medical and nursing care across the AMC must be antecedent to the generally more prominent feature of overall service excellence. Only after achieving a uniform level of care would we be able to address nationally endemic deficiencies in service quality using a model program for our institution as a potential national bellwether.
Ongoing senior leadership involvement with the amenities unit was considered essential to its continued success. Accordingly, the steering committee continues to include a mix of respected senior faculty as well as hospital and nursing leadership and patient donors, just as it did at its inception. Operational meetings are held monthly to review quality of care and service issues. Medical director rounds are being instituted. The full oversight committee meets quarterly to review overall unit progress, receive philanthropic updates, and advance strategic planning. As was necessary in initially developing our model, a successful model and unit requires continual input from physicians whose stature garners endorsement of faculty and nursing colleagues, who encourage interdisciplinary interaction, and who remain involved in the unit and its goals.
Service excellence is perhaps the most obvious driving principle of amenities units nationwide. It frames a service ethic for all staff who come into direct or indirect contact with current and prospective patients and their family members. Service excellence is also the foundation for luxury hotel-style amenities, including everything from high-quality bed linens to concierge services for needs not related to health care. Such concierge services include obtaining and providing patients with specific publications, attaining transportation for family members, and caring for family members when patients are either undergoing a procedure or in surgery. These tangible amenities, along with a strong emphasis on personal privacy, clearly differentiate the style and feel of the unit from others in the hospital, creating an aura of exclusivity that often draws attention away from those not involved with the unit. We chose, however, to link service excellence to academic values by making traditionally exclusive amenities available to all patients, recasting access to the amenities program exclusively as a matter of choice in discretionary use of disposable income rather than as an arbitrary privilege of status.
Service excellence comprises two fundamental elements. Available amenities are covered by a nightly fee that is below that of the current market price of the top luxury hotel in the region (List 1). Additional fees for restaurant-quality guest meals and fee-for-service concierge delivery are equally reasonable. Local media response has reinforced that the level of service quality on the unit compares with highly rated luxury hotel services.12–16 The principles of equivalent academic health care and service excellence then shape the strategy of the model.
All personnel involved in the unit, from senior leadership through nurses, nursing assistants, and environmental service workers, received service training at the Ritz-Carlton hotel in Philadelphia before the unit opening. This training, with a strong emphasis on service excellence, was well received by all participants. The participants were asked to complete an end-of-course survey, commenting on the training and their overall experience. Responses were overwhelmingly positive, and many participants followed up with unsolicited complimentary e-mails. Important elements of this training were then incorporated into the working model of the unit and provided the basis for the ongoing operations. These elements include emphasis on individual responsibility and empowerment at every level of the operation, personalized service, and the goal of consistently exceeding patient expectations. Because of the excellent impression the Ritz-Carlton personnel selection process and training made on senior leadership attending the course, the prescreening of all clinical practice service personnel across the health system was subsequently outsourced to the company used by Ritz-Carlton, Talent Plus (Talent Plus, Lincoln, Nebraska), and all new clinical practice hires now participate in modified Ritz-Carlton training.
In particular, our vision for the unit, which emphasized the ability to provide excellent nursing care for a wide variety of both medical and surgical patients, required exceptional nurse leadership. Such leadership was absolutely necessary to avoid the common perception that amenities units may offer many comforts but that their nursing care is inferior to that of specialized units. Our amenities unit nurse manager was selected for her broad-based nursing skills and excellent leadership record in a unit with mixed medical and surgical patient population. Nurses on the unit were similarly selected for both their strong critical thinking and broad nursing skills. However, the overall nurse-to-patient ratio on the amenities unit (1:4 to 1:5) is equal to that of other medical–surgical units. Because many patients are prebooked for admission to the unit well in advance, and because there are significant fluctuations in unit occupancy, we take advantage of this unique opportunity to send nurses to specialty units for additional familiarization in subspecialty care when patients requiring greater levels of intensity and nursing specialization are booked for admission. Our use of these opportunities both enhances the comfort levels of referring physicians within the hospital and also markedly improves the overall spectrum of nursing skill on the amenities unit. Indeed, we believe that this concept is key to the success of the unit.
Occupancy and revenue
Adequate revenue and occupancy are, together, the operational principles of the model, and we redefined them from common health care understanding to fit an amenities model. Our redefinition includes the expected expansion in reimbursement profile and patient revenue to include the self-pay supplement, but it also encompasses enhanced patient donor gifts and gift prospects. Our broadened definition of revenue creates financial viability at reduced occupancy rates. National normative expectations for minimum occupancy in an amenities program within an academic, tertiary hospital are approximately 50% (Upscale Hospital Facilities and Patient Services conferences December 8–9, 2005, Orlando, Florida, and May 7–8, 2008, Atlanta, Georgia). This rate departs from the tertiary medical and surgical unit occupancy rates that exceed 90% with which many nurse and hospital administrators have become familiar in recent years.17 Additionally, because amenities unit patients tend to have short stays, with a significant elective surgical component, this unit sees greater day-to-day occupancy fluctuations than would occur in the overall hospital occupancy. An 80% occupancy is the threshold at which costs are covered and the model delivers financial return in our interim amenities unit with a per diem cost to patients of $350 to $450, without consideration of enhanced philanthropy. Accordingly, this principle of considering overall revenue from all sources—namely, third-party reimbursement, self-pay supplement, and philanthropy—is critically important in evaluating the economic viability of such a unit.
The fee structure for amenities, including the nightly fee and per-service fees, is fundamentally concrete to ensure equitable access to the unit. The fees are never waived, and the unit is open to all patients, except, as previously noted, those requiring critical or maternal–fetal care. In this manner, the amenities are separated from the health care delivered and are made accessible to any patient or family who wishes to pay the fee. Inability to pay is never presumed, and the program is made available to all.
Admission of the first Medicaid-insured patient to the unit, paid for by family members, was a milestone in making clear the program’s accessibility in addition to its focus on service excellence. This family’s use of discretionary income created a paradigm case. This case reinforced the validity of the strategic principles when the patient’s family chose the amenities unit for the patient’s hospital stay for the comfort they felt service excellence would offer. Indeed, the most frequent admitting physician to the unit is a busy head- and neck-cancer surgeon, whose patient population is one not usually associated with large amounts of discretionary income. In contrast to the traditional understanding of a successful hospitalization as a stay that manages the problem in less time than the expected stay for the applicable diagnostic related group (DRG) and without readmission, we more broadly defined the success of our amenities unit. Within our model, length of stay could match expectations for the DRG, but need not undercut it. More fundamentally, the success of care within an amenities unit relies in part on the patient’s choice to return because of satisfaction for urgent and, more importantly, all elective admissions. Thus, a subsequent elective admission for the same patient becomes a positive representation of a satisfied patient or family and is linked to potential cultivation of a base of patients whose personal profile and interests reveal them to be possible philanthropic prospects. In this group, the possibility that individuals will elect to financially support the additional dissemination of service excellence, or to provide funds for medical or nursing research, becomes reinforced through satisfaction with the care and service received in one or more hospitalizations.
The primary third-party payors for patients in our amenities unit by total revenue are Medicare and third-party commercial insurance. This is consistent with general medical and surgical units in our hospital and with other academic, tertiary hospitals. Self-pay patients remain in the minority, contrary to stereotypic misperceptions around amenities unit patients and discretionary income. Philanthropic gifts associated with patients who elected to utilize the amenities unit are attributed as potential revenue from the unit. However, gifts received are most frequently directed outside the amenities program to support medical school research, other capital projects, or service in other hospital programs.
Our experience has implications for other AMCs. We emphasize, for example, the opportunity to create amenities care consonant with academic values, and to move medical school philanthropy and academic hospital operations forward. Clinical research as well as medical student and resident teaching take place on the unit. However, the unit is not a major teaching site for any one service, and the degree of medical student and resident involvement varies significantly from service to service on the unit. There are prominent immediate benefits from the unit to the hospital itself. Aspects of service excellence have been extrapolated throughout the hospital, making the amenities unit something akin to a learning laboratory to better understand what satisfies patients. As a result of experience with the amenities unit and experience with Ritz-Carlton service training, we were able to dramatically enhance patient-service representative training for all front desk personnel across all clinical practices by more broadly incorporating the Ritz-Carlton training program across the health system. Patient satisfaction within the outpatient clinical practices has subsequently reached an all-time high. Additionally, whereas patient-service representatives across the clinical practices previously were typically selected on the basis of their technical skills, selection criteria now heavily reflect desired personality characteristics based on the Ritz-Carlton service model and preinterview profiling from Talent Plus.
Clinically, the maintenance of a uniformly excellent level of academic health care across the hospital’s usual care and amenities units is essential. Initially, for example, referring physicians expressed concern about the level of patient acuity and the commensurate level of nursing care that could be provided within a general medical–surgical amenities unit. However, our experience with this unit is that a well-managed and appropriately educated professional nursing staff exceeds the challenge of high patient acuity on diverse admitting services, within the context of strong interdisciplinary leadership. Medicare case mix index (CMI), a measure of patient-care complexity based on admission diagnosis, determines DRG payment. The average CMI for hospital admissions under Medicare is 1.0. Analysis of Medicare CMI for the first 18 months of operation of amenities unit demonstrates that the CMI for this unit and for the hospital by fiscal quarter reveal no clinical significant differences and are both significantly higher than most AMCs, clearly demonstrating physician confidence in the nursing model (Table 1).
We are currently monitoring other aspects of quality and success. A hospital-wide quality dashboard, specific at the unit level, includes such measures as bloodstream and urinary tract infections, patient falls, and skin breakdown. Patient satisfaction is measured using Press-Ganey inpatient satisfaction scores and Hospital Consumer Assessment of Healthcare Providers and Systems. Although both tools are benchmarked nationally, scores are aggregated from the entire hospitalization and attributed to the unit of discharge. Because many patients on the amenities unit are transferred from other areas in the hospital, neither of these satisfaction scores accurately reflects the specific experience on the amenities unit. Accordingly, unit-specific satisfaction measures have been piloted for the unit and should allow longitudinal tracking of patient satisfaction, but without the benefit of national benchmarking. Unit occupancy growth over time may be considered a proxy satisfaction measure both for referring physicians and patients. Occupancy has steadily increased, reaching 81% in July and a 72% overall average for the first quarter of FY2009. Additionally, philanthropy cultivated through one or more admissions is tracked over time. Philanthropic dollars from patients who elect to use the unit also provide a potential measure of both unit success and patient satisfaction. Such philanthropy may be used to support the research or educational missions of the AMC or to develop services throughout the hospital that are not reimbursable or otherwise supported. For instance, gifts may be used to purchase equipment or to fund enhanced social or other patient-care services. Philanthropy associated with the amenities unit now provides the cornerstone of patient philanthropy associated with both the hospital and university.
We are currently in the second year of the amenities program and are moving forward with additional quantitative and qualitative evaluation of both process and outcomes, and we plan to report these results separately. In addition to establishing how and what the program achieves in comparison with other units internally and comparable data sets externally, evidence generated necessarily moves discourse in academic medicine away from anecdotal concerns of perception or interpretation and toward the evidence and the best practices central to academic medicine and to the delivery of health care in an AMC.
Toward an Excellent Experience for All
An inpatient amenities unit creates significant potential issues and also potential opportunities within an AMC. Whereas an informal system of different levels of patient care may currently exist in AMCs, our introduction of an amenities unit provided the opportunity to clearly define the principle of providing one level of academic patient care while also providing the opportunity for anyone to use disposable income to gain hotel-style luxury amenities and enhanced service opportunities. With strong unit leadership, broad interdisciplinary involvement, and excellent nursing leadership, it is possible to develop a unit with the capability of managing patients with the same CMI as the rest of the hospital. Our financial model for the unit incorporates all sources of revenue developed by the unit, including enhanced philanthropy, and occupancy expectations are modified accordingly. Providing an exceptional service model within such a unit also provided us with an incubator for the broader implementation of service enhancements across an entire AMC.