Why do hospitals bare butts when there are better gowns around?

Every decade or so, the headlines reappear:

“Fashion designer Cynthia Rowley updates hospital wear for patients” (United Press International, June 1999)

“Diane von Furstenberg Redesigns the Hospital Gown” (GOOD, September 2010)

“The Hospital Gown Gets a Modest Redesign” (The New York Times, January 2018)

Each redesign, of course, targets the old-school, butt-baring gown that’s long been a touchstone of cultural commiseration in movies, TV, and comic strips.

But if everyone agrees that the old garments are horrible, and if fashion designers — working with doctors and nurses, no less — have created better gowns, why are we still having this conversation?

The higher cost of new gowns is a big reason why many hospitals still use traditional tie-in-the-back johnnies. In addition, some fans of the old design think the new versions aren’t patient-friendly enough, and the standard ones are just fine; they’re convenient and functional, giving easy access to parts of the body clinicians need to poke and prod.

“There’s now an effort to be more patient-centric, but really it’s the institutional viewpoint of what patient-centric means, not the individual’s viewpoint,” said Timothy Andrews, a health industry analyst at Booz Allen Hamilton, a Virginia-based consultancy. Andrews said he visits Boston hospitals regularly for diabetes and dermatology checkups, and he continues to receive traditional tie-in-the-back gowns.

“You might as well just walk around naked,” he said. “It’s probably easier — just give us a belt and a loincloth.”

For patients who still feel like the health care system leaves them flapping in the wind, there is reason for optimism.

“The first thing hospitals do is strip patients of their dignity,” said Bridget Duffy, chief medical officer of Vocera, which focuses on health care operations and communications. But hospitals are increasingly paying attention to patients’ experience, and that includes what they wear, she said: “I have a little bit of hope now.”

As Cleveland Clinic’s first chief experience officer in 2006, Duffy started the process of redesigning the institution’s gowns, which culminated, seven years later, with new apparel created by Diane von Furstenberg. The gowns feature deep V-neck (and back) cuts that offer clinicians easy access to the patient’s upper torso, with full coverage of the patient’s lower extremities.

Duffy played a role in a more recent redesign effort, as well. Last spring she volunteered with students and faculty at New York City’s Parsons School of Design, where they created a line of hospital gowns for the health apparel company Care+Wear. It is testing the gown at Montgomery Medical Center, a nonprofit community hospital in Olney, Md.

The gown resembles a kimono, wrapping the patient and tying in the front. At the back, the gown splits just below the patient’s buttocks, and the fabric overlaps broadly to prevent accidental exposure.

Other hospitals have mostly ignored Cleveland Clinic’s example, Duffy said, but she’s trying again because hospitals now have a financial incentive not to force patients into gowns that are uncomfortable, ugly and frequently humiliating: If hospitals boost patient-satisfaction scores on surveys, they can increase Medicare and Medicaid reimbursement levels.

That sort of calculus has driven interest in the new gowns, said Chaitenya Razdan, Care+Wear’s chief executive. At the recent J.P. Morgan health care industry conference in San Francisco, Razdan said hospital executives were eager to meet.

“I’ve gone four years in a row, and this is the first time that in every hospital presentation, ‘patient experience’ was one of the three core focus areas for the year,” he said.

But the medical staff’s experience was also important to designers of his new gown, Razdan said. His team sought a gown simple enough that nurses, physicians, and medical assistants needn’t consult a lengthy user’s manual before examining a patient. With nearly 590 million patients admitted to hospitals annually, even tiny delays in patient care add up to huge costs.

The Parsons design team also sought input from suppliers of raw materials, and, importantly, industrial launderers, who increasingly own the garments hospitals use.

As would be expected from a company with a smaller manufacturing base than the industry giants, Care+Wear’s gowns cost more than tie-in-the-back versions, for which hospitals will pay between $4 and $7 apiece, according to TRSA, a trade group representing suppliers and launderers.

Razdan would not disclose pricing details, but said his “are definitely not adding an insane cost.”

Some doctors and nurses believe the seemingly simple measure of changing patient garb could have implications for a patient’s physical and mental health, but few researchers have addressed the issue in depth.

In a 2014 opinion piece published in the Journal of the American Medical Association, and titled “Reducing the Trauma of Hospitalization,” the research physicians Allan Detsky of the University of Toronto and Harlan Krumholz of Yale University argue that the many fleeting indignities, inconveniences, and personal violations suffered by patients may contribute to “post hospital syndrome,” and, in turn, could be related to otherwise-unnecessary hospital readmissions.

Among other things, they argue that patients should be encouraged to wear their own clothes more frequently, “to help them maintain their self-esteem and orientation,” and “remind their care professionals to recognize them as people.”

In an email exchange, Krumholz wrote: “It’s time to truly treat patients with the respect they deserve and not put them in a dependent, submissive position — starting with a gown that can be a symbol of becoming a faceless patient rather than an individual with a name and a history and a specific need.”

Some in the industry argue that respectful garments are already widely used, and the public is holding outdated perceptions of hospital gowns. Liz Remillong, a vice president with Crothall Healthcare, said none of the more than 500 hospitals in the U.S. that rent its garments use gowns that tie in the back.

“I’m in hospitals all the time. I bet you’d not find someone with their butt hanging out,” she said. “But look — it’s fun to see pictures of people walking down the hall with their butt hanging out. That’s the joke, right?”

Among the top 5 hospitals named to U.S. News & World Report’s most recent “Best Hospitals Honor Roll,” two, Johns Hopkins Hospital and the University of California San Francisco Medical Center, said their most commonly used patient gowns still tie in the back, and at UCSF the fabric does not overlap.

Cheaper designs are still in use in other hospitals, too, including those with little or no overlapping fabric in the back, and ties that can make it challenging for those with limited flexibility or dexterity to tightly secure the gown behind them.

Ken Koepper, a spokesman for TRSA, said roughly 14 million new gowns are put into service every year, with 1.4 million in use on a given day. Member surveys suggest that hospitals have indeed moved to higher-quality fabrics and more user-friendly designs in recent years. And because Americans have grown larger in recent history, Koepper said, more oversize gowns are available.

That said, tie-in-the-back gowns still represent “not an overwhelming majority, but still the majority” of patient gowns, he said.

Why haven’t patients gotten the memo that everything is improving? Increasing use of disposable paper gowns could be one reason. Doctors and nurses, speaking privately, said they frequently apologize to patients for the discomfort of these stiff, scratchy, thin garments.

Koepper said most hospitals use a “one size fits most” strategy, assuming that smaller people will be adequately covered. In fact, even for people who are only slightly smaller than average, nurses say these gowns can gape at the chest and back, leaving patients’ bodies exposed to anyone standing nearby. This is an issue for side-tie gowns, not just those that open in the back, doctors and nurses say.

At Cleveland Clinic and at Hackensack University Medical Center in New Jersey, response from patients and clinicians to their designer patient gowns has been enthusiastic enough to sustain the initiatives.

Both, it should be noted, still carry traditional gowns, for patients who are immobilized in the intensive care unit, for instance, and for whom clinicians need full and quick body access.

Hackensack was among the very first to target the old gown, calling on Cynthia Rowley for the design and another noted fashion designer, Nicole Miller, for fabrics. (Miller’s name is on the label.) Nancy R. Corcoran-Davidoff, executive vice president and chief experience officer of Hackensack Meridian Health, said staff members embraced the new apparel, which includes scrub pants for some patients, largely because they were involved in the design process from early on. “They mocked up different versions for us to try,” she said.

The hospital spends slightly more than $15 apiece on the apparel, and budgets $192,000 for annual replenishment, compared to $96,000 for the old gowns. “For most hospitals, with declining reimbursements, people want to immediately go to [eliminating] these kinds of things when they want to cut costs,” she said. “But we made a commitment.”

At Cleveland Clinic, von Furstenberg initially wanted to try an all-cotton gown, said Jeanne Murphy, the institution’s executive liaison, who was involved in the redesign effort, but the fabric held up poorly under repeated washing. Velcro attachments balled up in the laundry, so they, too, were out.

Metal snaps, the plunging neckline and backline, and a soft cotton/polyester blend, did the trick. Von Furstenberg included a wide flap of fabric that overlaps in the back, sparing patients from unintended southern exposure. And Cleveland Clinic carries four sizes, to accommodate a wide range of patients.

Cleveland Clinic paid Standard Textile, a major manufacturer of hospital linens, roughly $15 apiece to produce the gowns when they debuted. They last longer than the older versions, but they also cost around $10 more apiece.

“It’s been a leap we were willing to take, and we’re glad we took it,” Murphy said. “Patients are more comfortable, more dignified, more covered. A little more stylish.”

If there were any doubt patients preferred the new gowns, administrators discovered an unexpected compliment, buried in the financials. The hospital needed to reorder more than they had projected.

Were they getting destroyed in the laundry? No.

Patients liked them so much they were sneaking out with them.