Friday, May 14, 2004

Patient Satisfaction Surveys and the Emergency Department

We just received preliminary and sobering results of our annual fourth quarter patient satisfaction survey, but more about our results later. The process we and our hospital use differs from the usual commercial patient satisfaction survey so, but since its value to us in the ED is so great, I thought it might be worth sharing with you. I’ve also recently learned of another approach—driven by the emergency physician group practice itself—that may hold some interest for you. So let me review these approaches; while neither may work as a “drop-in” for your environment and both have real expense, perhaps you can learn something you can use.

Our hospital conducts structured over the telephone interviews on admitted and discharged patients, interviewing sufficient numbers of patients to garner completed interviews with 100 patients monthly. Patients are interviewed in their language of choice including English, Spanish, Yiddish, Russian and more recently Mandarin Chinese. Arabic may be next. During the months of October, November and December both Pediatric inpatients and ambulatory patients are surveyed. We also survey ER outpatients and the care-givers of pediatric ER outpatients using an instrument designed in parallel with the adult/pediatric inpatient tool. The inpatient tool attempts to determine both by direct questioning and by confirmatory questions whether the patient was first whether the patient was admitted through the ER and if so asks seven questions relevant to the ER experience, only one of which could be considered to ask about the emergency physician. The question is broadly focused asking about all physicians that may have been involved in the patient’s care. We do not tie the individual patient’s comments back to a specific provider.

Both we and hospital administration look at the survey results as giving us useful information about systems and processes, not individual providers. What we do get is wonderful information that allows us to compare the experience of adult and pediatric patients admitted and patients discharged from the ER as well as longitudinal results over time.

Results include an analysis of both positives and negatives. We aim for no more than 10% in the bottom “strongly disagree” box and 90% in the top two “agree” and “strongly agree” boxes. Survey items are all posed in the affirmative. Our results since 2001 (survey conducted monthly, results reported quarterly) conform to Boudreaux and O’Hea’s findings that patient satisfaction is most affected by the quality of interaction with the ED provider.[1] Waiting time, perceived or real and the discordance among perception and expectation were a secondary factor in this literature review and analysis of opportunities for further study.

I’ve learned of two variations on an emergency physician centered patient satisfaction “survey” both of which I would characterize more as “callback” efforts intent upon enriching the patient encounter and improving patient satisfaction themselves. In both instances the emergency physician practices themselves conduct the process.

Tom Scaletta, MD, Chair, Dept. of Emergency Medicine, Edward Hospital in Naperville, Illinois, the emergency physician who designed and implemented the process describes his approach thusly:[2] “The callback clerk attempted to reach a cohort of all discharged patients. She called about 3,000 a month and reached about one-third. What she said was carefully scripted. Patients getting worse were told to call their PCP [primary care provider] or come back to the ED immediately. No further medical advice was given by the callback clerk though, if requested, the call was transferred to a nurse. The cost (about $36K a year) was about $1 per patient attempted or $3 per patient reached. This was a fulltime position by an administrative assistant with great interpersonal skills. Her job was facilitated by a callback database (FileMaker Pro™) which uploaded the prior day's census, automatically dialed, and served as a user-friendly way to store the data.”

“The callback information was used to improve satisfaction—the act of checking on patient’s well being was positively received. We uncovered problems quickly and made recommendations to correct or documented improvement and assured adequate follow-up. All this helps minimize risk. Finally, we collected data on opportunities for the physician, nurse, and system to improve. We used a letter grade since patients immediately understood what we were getting at and a portion of the doctors’ bonus was tied to this grade. Overall, the docs received an ‘A’ 70% and a ‘B’ 25% of the time. The ratio of A:B was more influential than A/B:C/D/F in comparing the docs. The docs received monthly feedback and many were able to change their means of interacting with patients and improved their scores significantly.”

The other physician driven approach takes advantage of integrated information systems and telecommunications technologies to use automated dialing to leave a message in the physician’s voice to the patient. The message advises the patient to call 911, return to the ED or see their primary care provider if not improved or worse. It then goes on to solicit feedback with any concerns or comments regarding the patient’s care or experience in the ED. A patient request for a callback from the physician receives that response.

Our patient satisfaction survey results served as a sharp rejoinder to any complacency, reminding me that while excuses abound: space, staffing resources, upstairs-downstairs communication and conflicts; I must periodically remind myself and re-energize all staff in our commitment to care of our patients within the resources available. Patients and their families take for granted that they are getting good clinical care; caring for the patient must go beyond the clinical realm alone.

[1] Boudreaux ED and O’Hea EL: Patient Satisfaction In The Emergency Department: A Review Of The Literature And Implications For Practice, J Emerg Med 2004; 26(1) 13-26

[2] viewed on 2004 March 16

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