From Express Admission to patient experience education and cultural competence
In 1995, Mary Anne Keyes and I published an article in Nursing Management titled “Express admission: An experiment in front-end redesign.” At the time, we were trying to solve a very practical problem: patients entering the hospital were moving through a system organized around departments rather than around their needs. Three decades later, I find myself asking a difficult question: How much has really changed?
We now have defined patient experience discipline, national surveys, sophisticated technology, and a greater understanding of cultural competence. Yet we still hear about delays, call bells not answered in a timely manner, meals served at the wrong temperature, fragmented communication, patients repeating their stories, and families who do not understand what happens next. The language has evolved. Many of the underlying needs have not.
Express Admission at Muhlenberg
At Muhlenberg Regional Medical Center in Plainfield, New Jersey, admissions were fragmented. Physicians needed information and treatment to be initiated sooner. Nurses were admitting patients while caring for those already on their units. Patients moved between locations as departments completed separate tasks. Each department was doing its work, but no one experienced the journey as a whole.
Our multidisciplinary team brought together nursing, physicians, administration, respiratory therapy, laboratory, pharmacy, radiology, and other departments. We redesigned the front end of hospitalization, coordinating essential assessments, orders, diagnostic work, and initial treatment through a centralized Express Admission Unit with cross-trained staff.
Before the redesign, hospital policy allowed nurses 24 hours to complete the nursing assessment and care plan. Our 1995 Nursing Management article reported that all patients in the pilot completed admission in 80 minutes, measured from arrival at the Express Admission Unit to transfer to the assigned bed. These figures describe different parts of the process, rather than a direct before-and-after timing comparison. The pilot also reported favorable patient and staff evaluations. For me, the lesson was that changing the system around the patient could improve both the experience and the work. We put the patient at the center of what we do, not in the middle of it.
We were practicing patient experience improvement before I used that term as I do today: examining operational data, challenging departmental boundaries, and redesigning care across professional roles. Our goal was to reduce frustration and delays, initiate appropriate care sooner, and give patients and families a coordinated beginning to their stay.
Efficiency matters, but a fast process that leaves someone confused, unheard, or frightened is not truly patient-centered. Reducing unnecessary steps should create room for meaningful interaction with patients.
Revisiting the work
In my 2016 blog, “Learning Patient Experience in the Dark Ages,” I revisited what we accomplished at Muhlenberg—and what I had not fully understood. We had mapped the patient journey and challenged silos, but were efficiency and higher satisfaction scores enough to call the experience transformed?
Although we considered patients in our decisions, we had not engaged them as meaningful partners in redesigning care. We needed to listen more intentionally, understand their expectations and preferences, and ask what they would define as an excellent experience. That realization continues to shape my work.
The needs that remain
Patients still need timely care, understandable communication, responsive staff, coordination, and respect. Contemporary HCAHPS measures address many of these same needs, including communication with nurses and doctors, care coordination, staff responsiveness, and discharge information.
National HCAHPS trends show progress, but uneven gains. A 2024 study of 3,909 U.S. hospitals found that the average share of most-positive responses across the HCAHPS summary score rose by 5.2 percentage points from 2007 to 2019. Gains included 8.5 points for overall hospital rating and 6.5 for nurse communication, compared with 0.8 for doctor communication. Improvement slowed after 2013.
HCAHPS public reporting began in 2008, so these findings are not a direct thirty-year comparison with our project. CMS also changed the survey in 2025, requiring care when comparing newer and older results. Measurement helps us identify problems; sustained improvement depends on what we do with the findings.
Healthcare has advanced in safety, digital records, AI, care delivery, and access to information. Yet patients can still face disconnected departments and explanations they do not understand. Patient experience depends on how leaders translate knowledge into daily practice across the organization.
Cultural competence and individual needs
My thinking has also grown in another respect: there is no single, universal “patient” for whom we can design an ideal experience. People bring different languages, cultures, beliefs, health literacy, family structures, abilities, and expectations. What feels clear and respectful to one person may not feel that way to another.
In the PXS™ curriculum I developed for PXAcademy, we teach patient persona development as part of journey mapping. The “Persona Creation” section in the course explains how representative patient profiles draw on demographic, socioeconomic, and psychographic characteristics. This helps teams consider how people’s circumstances, attitudes, and expectations shape their journeys through care.
For an admission team, that means asking how the same process might be experienced by someone with limited English proficiency, someone with a sensory disability, or someone balancing treatment with work and caregiving. Personas help us examine those differences; conversations with patients help us test our assumptions and understand each person’s needs.
Express Admission taught me to look through the patient’s eyes. Cultural competence makes me ask: Which patient’s eyes? Are we asking what matters to this person, checking understanding, and respecting preferences about decisions, family involvement, communication, and care? These questions are essential to patient-centered practice.
Preparing professionals to improve patient experience
These lessons inform my work with PX Academy, a subsidiary of CX University, and our Patient Experience Specialist (PXS™) education. The discipline requires a foundation in strategy, patient-centered culture and accountability, measurement and analysis, improvement and design, and the voice of patients and professionals. Cultural competence education helps practitioners apply that foundation to diverse needs.
We cannot expect excellent experiences without teaching healthcare professionals to interpret feedback, examine root causes, collaborate across departments, and design services with patients. These skills require practice and reinforcement. Leaders, too, need preparation to build and sustain a patient-centered culture.
The lesson I would carry forward
I am proud of our work at Muhlenberg. Its lasting value was a willingness to question a familiar process and redesign it together. Today, I would bring patients into that work as partners from the beginning.
Thirty years later, recognizing patient experience as a discipline is only a starting point. Delivering it consistently requires educated professionals, committed leaders, culturally competent teams, and accountability for how care is experienced. This requires educated staff around their role in experience and leadership commitment to it.
The question I would carry forward is simple: How would we design care if we began with the people receiving it—and kept listening as their needs changed?
Sources and historical notes
Keyes, M. A., & Biedron, J. (1995). Express admission: An experiment in front-end redesign. Nursing Management, 26(10), 39–40. https://pubmed.ncbi.nlm.nih.gov/7566805/
Agency for Healthcare Research and Quality. CAHPS Adult Hospital Survey (2025 measure set). https://www.ahrq.gov/cahps/surveys-guidance/hospital/about/adult_hp_survey.html
[1] Biedron, J. (2016, November 25). Learning Patient Experience in the Dark Ages. LinkedIn. Read the original blog
[2] Beckett, M. K., Quigley, D. D., Cohea, C. W., et al. (2024). Trends in HCAHPS survey scores, 2008–2019: A quality improvement perspective. Medical Care, 62(6), 416–422. https://doi.org/10.1097/MLR.0000000000002001
[3] Centers for Medicare & Medicaid Services. Hospital CAHPS (HCAHPS): survey overview and 2025 changes. https://www.cms.gov/data-research/research/consumer-assessment-healthcare-providers-systems/hospital-cahps-hcahps
[4] PXAcademy. PX 703 Design. PXS™ course curriculum developed by Janet Biedron. Lesson 2, Patient Journey Mapping, Development Process, “Persona Creation,”.
