Patient Satisfaction Surveys and the Emergency Department

FigureWe just received preliminary (and sobering) results of our fourth-quarter patient satisfaction survey. The process we use differs from the usual commercial patient satisfaction survey, but its value to the ED is so great that I thought it might be worth sharing with you. I've also recently learned of another approach — driven by the emergency physician group practice — that may hold some interest for you. While neither may work for your environment, perhaps you can learn something you can use. Our hospital conducts structured telephone interviews on admitted and discharged patients, talking to sufficient numbers of patients to garner completed interviews with 100 patients each month. Patients are interviewed in their language of choice, either English, Spanish, Yiddish, Russian, or more recently Mandarin Chinese. Arabic may be next. Patient satisfaction surveys remind ED staff that caring for the patient must go beyond the clinical realm alone During October, November, and December, pediatric inpatients and ambulatory patients are surveyed. We also survey ED outpatients and the caregivers of pediatric ED outpatients using an instrument similar to our adult/pediatric inpatient tool. The inpatient tool attempts to determine by direct questioning and confirmatory questions whether the patient was admitted through the ED. If he was, seven questions relevant to the ED experience are asked, only one of which is about the emergency physician. The question is broad, and asks about all physicians that may have been involved in the patient's care. We do not tie patients' comments to specific providers. The emergency department and the hospital administration look at the survey results as useful information about systems and processes, not individual providers. What we do get is wonderful information that allows us to compare the experience of admitted patients with discharged patients as well as longitudinal results over time. Results include an analysis of both positives and negatives. We aim for no more than 10 percent in the “strongly disagree” category and 90 percent in the “agree” and “strongly agree” groups. Survey items are all posed in the affirmative. Our results since 2001 (the survey is conducted monthly; results are 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 (J Emerg Med 2004;26[1]:13). Waiting time, perceived or real, and discordance among perception and expectation were a secondary factor in this literature review and analysis of opportunities for further study. Variations on a Theme 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 on enriching the patient encounter and improving patient satisfaction. In both instances, the emergency physician practices conduct the process. Tom Scaletta, MD, the chairman of the department of emergency medicine at Edward Hospital in Naperville, IL, designed and implemented the process, and he describes his approach like this: “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 [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 full-time 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.” (J Emerg Med 2004;26[1]:13.) 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 them, documented improvement, and ensured 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 because patients immediately understood what we meant. A portion of the doctors' bonus was tied to this grade. Overall, 70 percent of the doctors received an A, and 25 percent received a B. The ratio of A:B was more influential than A/B:C/D/F in comparing the physicians. They received monthly feedback, and many were able to change their means of interacting with patients to improve 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 9–1-1, return to the ED, or see his primary care provider if he is not improved or has gotten worse. It then solicits 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 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 for 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.

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