‘Halo effect’: room impacts patient perception of overall hospital experience

Abstract

Private hospital rooms offer potential advantages over semiprivate rooms, but the impact of room type on patient experience across multiple dimensions of care remains understudied. A retrospective study was conducted to investigate how room type influenced patients’ perception of their experience at Stanford Health Care, a large university medical centre in California, USA. Hospital Consumer Assessment of Healthcare Providers and Systems survey data from medicine patients discharged from January 2018 to January 2020 (n=891) was analysed. The percentage of top responses was calculated for 18 survey sections including overall assessment. Patients in private rooms were more likely to give a top response (aOR, 1.30; 95% CI, 1.24 to 1.36), rating overall assessment and 10 other sections significantly higher than patients in semiprivate rooms. The greatest differences were in survey sections related to the room (room, hospital environment and visitors/family). However, private rooms also performed better on sections not directly related to room type (tests/treatments, care transitions and discharge). These widespread improvements suggest a ‘halo effect’, in which a patient’s positive impression of their room may enhance their perception of overall care. These findings underscore the substantial influence of the care environment on patients’ perceptions of their overall hospital experience.

Introduction

In the nineteenth century, US hospitals widely adopted the pavilion-ward design with shared spaces that provided natural light, ventilation and improved cleanliness.^{1 2} Today, medical institutions have largely transitioned to the use of private rooms,³ which can improve privacy,^{4 5} noise insulation^{6 7} and communication with physicians.⁸ Nurses have also reported that private rooms facilitate better interactions between families and hospital staff.⁹

However, semiprivate rooms remain a viable care environment. Previous studies found that hospice patients favoured shared rooms that offered opportunities for socialisation,^{5 6} and nurses preferred having more patients accessible at once.¹⁰ With many hospitals at overcapacity, semiprivate rooms may be necessary to accommodate more patients.

The impact of room type on patient experience across multiple aspects of care has not been extensively explored. This study examined how patient perceptions differed between those in semiprivate rooms and those in private rooms.

Methods

Study setting

This study included medicine patients discharged from January 2018 to January 2020 (n=891) at Stanford Health Care, a large university medical centre in California, USA. Patients were assigned to a room to optimise co-location unless they required a private room for infection precautions.

Survey

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey evaluates patient experiences in US hospitals. Patients over the age of 18 who had an inpatient stay longer than 24 hours and did not meet no publicity criteria received the survey by mail. Responses from 18 survey sections, each containing 2 to 7 questions (scale system or yes/no), were analysed (online supplemental table S1).

Statistical analysis

A multivariate regression estimated the effect of room type on the likelihood of giving a top response, adjusting for the hospital and patient characteristics. Following the quality reporting method used by the US Centers for Medicare & Medicaid Services, a top box score, representing the percentage of responses with the highest rating, was calculated for each section. A χ2 identified differences between scores of patients in semiprivate and private rooms. A significance level of .05 was used for all tests.

Results and discussion

Patients in private rooms were more likely than those in semiprivate rooms to give a top response (aOR, 1.30; 95% CI, 1.24 to 1.36) (table 1) for overall assessment (76% for private vs 71% for semiprivate, p=0.013) and 10 other sections: visitors/family (69% vs 53%, p<0.001), room (50% vs 38%, p<0.001), hospital environment (52% vs 44%, p=0.0033), physician (73% vs 65%, p<0.001), human caring (69% vs 62%, p=0.0023), personal issues (67% vs 60%, p<0.001), tests/treatments (65% vs 58%, p<0.001), care transitions (59% vs 52%, p=0.020), nurses (75% vs 69%, p<0.001) and discharge (62% vs 57%, p=0.038) (figure 1).

Table 1. Unadjusted and adjusted ORs estimating the effects of room type, hospital and patient characteristics on likelihood of a top response on HCAHPS survey (n=891).

		Unadjusted OR (95% CI)	Adjusted OR (95% CI)
Room type	Semiprivate (reference)	1.00	1.00
	Private	1.35 (1.30 to 1.40)***	1.30 (1.24 to 1.36)***
Hospital	Original (reference)	1.00	1.00
	New	2.04 (1.82 to 2.22)***	1.56 (1.41 to 1.75)***
Gender	Female (reference)	1.00	1.00
	Male	1.13 (1.09 to 1.17)	1.11 (1.07 to 1.16)***
Marital status	Married (reference)	1.00	1.00
	Single	1.02 (0.98 to 1.07)	1.08 (1.02 to 1.13)**
	Widowed	0.91 (0.86 to 0.97)**	0.91 (0.85 to 0.98)**
	Divorced	1.03 (0.95 to 1.12)	0.98 (0.90 to 1.07)
	Life partner	0.89 (0.75 to 1.05)	0.80 (0.66 to 0.96) *
	Separated	0.67 (0.56 to 0.79)***	0.78 (0.64 to 0.94)**
	Unknown	1.62 (1.10 to 2.40)*	3.52 (1.67 to 7.48)**
	Other	0.21 (0.12 to 0.37)***	0.27 (0.16 to 0.48)***
Religion	No religious preference (reference)	1.00	1.00
	Catholic	0.97 (0.93 to 1.02)	0.92 (0.87 to 0.97)**
	Christian (non-specific)	1.12 (1.05 to 1.19)***	1.14 (1.06 to 1.22)***
	Protestant	0.96 (0.87 to 1.06)	0.90 (0.81 to 1.00)
	Buddhist	0.91 (0.81 to 1.02)	0.92 (0.80 to 1.07)
	Other	1.09 (1.04 to 1.15)***	1.08 (1.02 to 1.14)*
Language	English (reference)	1.00	1.00
	Spanish	1.06 (0.98 to 1.14)	1.14 (1.03 to 1.27)*
	Vietnamese	0.99 (0.87 to 1.12)	0.79 (0.67 to 0.94)**
	Mandarin	2.13 (1.79 to 2.54)***	1.76 (1.44 to 2.15)***
	Russian	1.35 (1.10 to 1.67)**	1.31 (1.06 to 1.61)*
	Other	0.64 (0.58 to 0.70)***	0.58 (0.52 to 0.64)***
Ethnic group	Non-Hispanic/non-Latino (reference)	1.00	1.00
	Hispanic/Latino	1.04 (0.99 to 1.10)	1.01 (0.93 to 1.09)
	Patient refused	0.61 (0.47 to 0.78)***	0.55 (0.38 to 0.79)**
	Unknown	3.99 (2.74 to 5.79)***	3.40 (2.28 to 5.06)***
Insurance type	Managed care non-capitated (reference)	1.00	1.00
	Medicare acute traditional	1.28 (1.21 to 1.35)***	1.28 (1.21 to 1.35)***
	Senior managed care non-capitated	1.10 (1.04 to 1.16)**	1.13 (1.07 to 1.20)***
	Medi-Cal managed care non-capitated	1.30 (1.22 to 1.38)***	1.29 (1.21 to 1.38)***
	Medi-Cal traditional	0.91 (0.83 to 1.00) *	0.97 (0.87 to 1.07)
	Other	1.02 (0.91 to 1.15)	0.98 (0.87 to 1.11)

*: p<.05, **: p≤.01, ***: p≤.001

HCAHPS, Hospital Consumer Assessment of Healthcare Providers and Systems.

Figure 1. Top box scores for HCAPHS survey sections by room type. (A) Top box scores for semiprivate and private rooms. (B) Differences between top box scores for semiprivate and private rooms. Bar colour indicates whether patients in semiprivate rooms reported a higher top box score (blue) or patients in private rooms reported a higher top box score (orange). (n.s., p>0.05; *p≤0.05; **p≤0.01; ***p≤0.001). HCAPHS, Hospital Consumer Assessment of Healthcare Providers and Systems.

Private rooms showed the greatest improvements relative to semiprivate rooms in the room, hospital environment and visitors/family sections. The isolation of private rooms may have led to positive responses regarding noise levels in the room and hospital environment. Furthermore, the additional space and privacy could have contributed to favourable ratings on accommodations and comfort for visitors. The significant increase in visitor-related scores highlights the importance of providing spaces that facilitate social support.

Patients in private rooms also reported better experiences in areas unrelated to the room itself, such as tests/treatments, care transitions and discharge. This suggests a ‘halo effect’, in which an impression formed from a single characteristic influences multiple judgements or an overall opinion,¹¹ a bias that has been proposed to influence marketing and politics.¹² These findings indicate this phenomenon can also occur in patient experience scoring, as positive impressions of the room correlated with better assessments of other aspects of the hospital experience.

Limitations

This study’s retrospective design identified associations between room type and patient perception but did not establish causation. While the survey response rate was 20%, the sample includes a large and diverse cohort, offering valuable insights into patient experiences at a major academic medical centre. However, this study did not account for the proximity of the rooms to hospital facilities, such as the nurses’ station, elevators and kitchens, which could influence staff responsiveness and noise levels. Future research should identify key features of the care environment that may have contributed to improved patient experience.

Conclusions

This study is the first to identify a halo effect related to room type, in which a favourable impression of the room extended to other aspects of care, informing initiatives to enhance overall patient experience. Beyond room type, these results highlight the importance of considering how environmental factors shape patient perception. Ultimately, these findings demonstrate the complex nature of patient experience, which is key to consider when developing patient-centred practices.