Managers Toolkit:

Improving the Patient Experience: “Quietness”

Toolkit #1: Quietness: All Staff Responsible and Empowered

Purpose/Rationale: Maintaining a quiet environment extends to all staff

Imagine walking down the hall wheeling a cart with a squeaky wheel. It may not seem like a big deal to a nurse who is thinking about his or her next patient or is going to leave the cart at his or her next stop. To a patient who is lying in bed and trying to get well, however, the sound may be aggravating enough to interfere with healing, and certainly stressful enough to mark you down on the HCAHPS.

Keeping some oil or grease on carts or in storerooms and teaching nurses and other staff to use it is an example of one small and inexpensive change that may have a big impact on your scores. Keep gurneys, wheelchairs, and carts in top condition; if they bang and clang, fix them on site or hire a repairperson.

Method: Ensure Maintenance Staff keep cart parts/wheels in good repair by adding it to environmental and rounding checklists for reporting issues as well as staff training;keep some oil or grease on carts or in storerooms and teach nurses and other staff to use it in case of an ‘after hours’ need.

Toolkit #2: Making Quietness at Night a Priority

Purpose/Rationale: Maintaining a quiet environment requires investment by all staff, patients, and visitors.

Nighttime noise is another concern. Patients need to sleep well if you want them to have a good hospital experience. While you cannot avoid all nighttime noise in a hospital due to monitors beeping and the night staff making their rounds — you can limit it. Restricting television volumes and cellphone use can make it easier for patients to relax and sleep.

Method A: Inform patients and visitors of expectations and restrictions on television volumes and cellphone use, especially at night, and use “Quiet Zone” signs in the corridors, implementing set quiet times each day when the lights are dimmed.

Quiet Zone Signs can be found online:(click image for link)

or you can download an image and customize to create your own!

Method B: The Noise Study: Six Sigma Noise Matrix

One recommended resource available online are tools to help you to analyze and set priorities for the noise levels in your hospital is online from Six Sigma.

You can find the resource posted below so that you can edit it for your hospital, or reference it online, here:

This sample Noise Matrix will allow you to collect information throughout the day in various parts of the hospital to help your team prioritize noise levels. You could also pair this activity with the use of a noise meter, above.

Reduce and Optimize Hospital Noise with Six Sigma Tools S. Arun Vijay

A hospital must create a quiet, calm environment for patients by providing a physical setting conducive to recovery and an organizational culture that supports patients and families through the stresses imposed by illness, hospitalization, medical visits, healing and bereavement.

To accomplish this hospital employees must identify internal and external noise factors – is it voices, equipment or the building? The staff must also discern which noise sources are known controllable factors, known uncontrollable factors and unknown uncontrollable factors. The hospital must measure and reduce the noise in patient rooms within defined compliance levels.

Impact of Noise

Noise impacts patients in many ways including:

  • Sleep deprivation
  • Increased anxiety
  • Increase in noise-induced stress
  • A “startle reflex” resulting in physiological responses:
  • Facial grimacing
  • Increase in blood pressure
  • Higher respiratory rate
  • Increased heart rate and vasoconstriction

Continuous noise may alter a patient’s memory, increase agitation, lower pain tolerance and lead to feelings of isolation.

Noise may also impact hospital employees causing:

  • Stress related symptoms.
  • Depression.
  • Irritability and decreased concentration in the work place.
  • Reduced efficiency and decreased productivity.
  • Increased medical and nursing errors.

Source of Hospital Noise

Table 1: Priority Matrix – Identify Noise with Respect to Sources
Location / Source: People
(Weighted Score, 0.40) / Source: Equipment
(Weighted Score, 0.50) / Source: Environment
(Weighted Score, 0.10) / Total Weighted Score
Reception (A)
Emergency department (B)
Outpatient departments (C)
Inpatients area (D)
Nursing station (E)
Diagnostic centers (F)
Pharmacy (G)
Operation theaters (H)
Intensive care units (I)
Canteen (J)
Laundry and linen services (K)

Using the Noise/Source Matrix

The matrix shown in Table 1 displays the source of noise in various locations of the hospital and records a mean weighted average, providing a clear picture of the noisiest hospital area and the worst noise source and establishing a clear priority of what to fix first.

Table 1: Noise Location Stratification According to Time of Day
Locations
(noise measured in decibels) / A / B / C / D / E / F / G
Time Period
9:00 a.m.–1:00 p.m.
1:00 p.m.–4:00 p.m.
4:00 p.m.–7:00 p.m.
7:00 p.m.–10:00 p.m.
10:00 p.m.–7:00 a.m.
7:00 a.m.–10:00 a.m.

Interpreting the Stratification Technique

By measuring noise during peak and off peak hospital hours, analysts can detect and correct the noise. Noise meter readings established by a pollution control board offer quantitative readings that help predict, and therefore prevent, future noise problems.

Strategies to Solve Noise Pollution

After identifying the primary sources for noise pollution, the following improvement strategies can be implemented:

  1. Establish stringent standards impacting patient safety.
  2. Evaluate the current hospital noise through patient satisfaction surveys and by measuring the decibel levels.
  3. Review the hospital’s repair and maintenance policy and ensure it reflects the need for equipment to operate effectively and quietly.
  4. Conduct an auditory impact query as part of every remodel and construction project, equipment purchase and staff event.
  5. Change the ceiling tiles periodically from sound reflecting to sound absorbing tiles allowing patients to sleep better.
  6. Convert a centralized nurse station to a decentralized nurse station.
  7. Provide curtains and Plexiglas barriers in multi-bed rooms to provide both visual and auditory protection.
  8. Use music therapy to replace noxious sounds with pleasant sounds – music improves restfulness and sleep, and induces relaxation.
  9. Provide guidance and instruction during staff education and employee orientation sessions on the importance of maintaining appropriate noise levels.
  10. Outline specific procedures regarding:
  11. Private discussions in public areas
  12. Use of pagers and cell phones
  13. Nurse call systems
  14. Telephone use
  15. Place signs and slogans throughout the hospital – silent hospital help healing (SHHH) – and give patients, staff and visitors buttons that show a nurse with her finger to her lips.
  16. Use sound meters to record ambient noise level at periodic times throughout the day.
  17. Reduce waiting time in the outpatient departments. Schedule consulting times for the patients and fix appointments with the physicians during registration. Reducing the waiting time in turn reduces noise in the outpatient departments.
  18. Display the location of offices and consultants at the reception area, and provide directories on each floor to minimize the need for visitors and patients to ask for directions.
  19. Use an individual activity network diagram for each student in the hospital and ensure the faculty oversees the students in the clinical setting. This will minimize overcrowding of students in the clinical setting and streamline student activities.
  20. Implement a SHHH program to recognize hospital staff and/or departments that excel at providing and maintaining a noise free environment.

Table 3: Noise Sources
Sources of Noise / Primary Area / Secondary Area / Tertiary / Location
People / •* Unwanted movements of people(patients/ employees)
••* Pooling of intermediate customers during consultation timing (representatives)
••* Exchange of information between employees (human voice)
••* Too many attenders accompanying the patients / ••* Frequent visiting of patient’s attenders in the nursing station/laboratory services for inquires
•*• Pooling of students in the nursing station
•*Mishandling of accessories, which creates excessive noise
•*• Load glucometer carts
••* Staff tend to have mini-conference in the hallway creating noise / •*• Frequent movement of people in parking facility creates unavoidable noise
•*• Overcrowding of patient attenders in the canteen
•*• Noise due to renovation/repair work done in the hospital / •*• Noise created by people from outside the hospital (public meeting announcements)
Equipment / •*• Ambulance noise
•*• Patient vehicles
•*• Mobility aid sounds
••* Telephone sounds
••* Overhead paging systems
••* Lifts operating noise / ••* Equipment handling
••* Noise in laboratories
•*• Mobility aids and wheelchair sounds while transferring patients
•*• Lifts operating noise
••* Telephones, trip alarms and intercom sound of beepers, bed rails, and ventilators
•*• Portable X-ray machine sounds, blaring T.V.
•*• Buzzers, beepers, multiple monitors, nurse call systems and doors / •*• Frequent movements of vehicles
••* Handling of equipment in the laundry and linen services
••* Noise created during transfer of incoming essential materials in the purchase departments
••* Utensils handling noise in canteens / ••* Vehicle sounds
Environment/ system / •*• Improper/confused facility arrangements
•*• Lack of display boards showing facilities available in the hospital leads to unwanted enquires resulting in noise / ••* Centralized nursing stations
•*• Facility arrangements warranting noise in inpatient wards
•*• Excessive students to patient ratio creates noise during clinical teaching / •*• Lack of knowledge in handling the equipments by workers involved in maintenance departments
•*• Lack of space required for supportive services / •*• Hospital floor, wall and ceilings are hard and reflect sound rather than absorb it

Using quantitative and qualitative measures to identify and monitor noise levels in hospitals is critical to hospital efficiency. Reducing noise and maintaining a quiet facility will improve patient care and enhance the reputation of the hospital.

Method C: Use noise meters at nurses’ stations

Noise control products to provide a better patient experience in hospitals and medical centers. Often staff can become desensitized to the normal noises in their environment that might otherwise disturb patients. Even with useful measures put in place to help reduce noise levels, the presence of a Noise Warning Sign or Noise Meter can make a great deal of difference to the behavior of visitors, staff and even the patients. Using noise meters does not have to be cost-prohibitive; some companies will rent machines, or they can be shared and passed between facilities to perform periodic “noise check ins.” Other inexpensive options are also available. (See The Noise Study above, in which a formal analysis can be performed of noise levels.)

You can display a meter visible to everyone: ;

You can also download an app!

Method D: Provide patient alternatives such as white noise machines, CDs with relaxing music, or ear plugs (can be included in patient kits).

According to one study, “The Effect of White Noise Machines in Decreasing Hospital Nose: A Bedside Scientist Project” by Anne Arundel Medical Center, a clinical review of sleep reduction strategies found that sound masking using white noise in a hospital setting is the most effective technique in improving sleep. Another hospital found that after installing white noise machings in their telemetry unit the patient satisfaction results increased by 20%. (View the study online.)

While commercial grade purchases can be cost-prohibitive, as a part of your commitment to creating a quiet, supportive environment, you can make a few less expensive investments that you can make available to patients upon request. Some examples are below.

White Noise Machines:

CDs with relaxing music:

Ear Plugs:

Toolkit #3: Implement QuietTimes

Purpose/Rationale: Maintaining a quiet environment requires investment of all staff, patients, and visitors.How are quiet times structured? Many units designate 2 hours in the afternoon and 4 hours during the night as quiet hours.Common structure is from 1 – 3:00 pm in the afternoon and from 10:00 pm – 2:00 am during the night. Shift changes need to be considered in selecting the designated quiet hours.

Method: Staff remind patients, their families, and each other about quiet hours during their rounds.

Method: Quiet time checklist –

  • Lights are turned down across the unit and in patient rooms as a visual cue.
  • Overhead paging is minimized.
  • Phone conversations are allowed only in designated areas away from patient rooms.
  • Clinical interventions (vital signs, blood draws, etc.) are minimized or eliminated during these hours.
  • Quiet hours are designated by signage placed throughout the unit.
  • Staff police each other in observing quiet hours.Some units designate “quietness champions” to help keep everyone’s awareness and observance at high levels.
  • Provide patient and visitors with a notice of construction or repair work that may create noise or vibrations, interrupting quiet time.

Method: Develop Scripted responses for broaching the subject of quietness with patients, visitors, and coworkers (examples provided).

With Patients: It is important to convey to the patients that the goal is to make them comfortable and to create a quiet environment.

  • “We ALWAYS want to keep your room quiet at night so you can rest – would you like us to close your door?We will be in to check on you approximately every two hours throughout the night.”
  • “To ensure your roommate gets the rest needed, would you mind lowering the TV volume?”

With Families and Visitors: It’s important to develop key words when there are noisy roommates, family issues, or too many visitors.

  • “We want to provide the best healing environment for all our patients.Would you mind lowering your noise level to help our other patients get the rest they need?”

With Colleagues: Sometimes staff are unaware of how their voice levels project and may need a gentle reminder from a colleague.

  • “I wanted to let you know that I noticed that your voice can be heard in patient rooms.”