The Patient Experience: Why Is It Important? Why Do We Hate It So Much? What Can We Do To Improve?

Author: Justin Bright, MD (Senior Staff Physician, Henry Ford Hospital, Department of Emergency Medicine, Detroit, MI (@JBright2021)) // Editor: Alex Koyfman, MD (@EMHighAK)

To start, I have a few disclosures to make.  I have no financial relationship with any patient satisfaction survey company.  I have been practicing emergency medicine as an attending physician since July 2010.  I presently work as a hospital employee and core academic faculty in a massive level 1 trauma center in inner city Detroit which has a large emergency medicine residency program.  I formerly worked in the community for a private physician group in Toledo, OH that owned the contract for 4 emergency departments within a larger health care system.  Between residency, moonlighting, and attending jobs, I have pulled shifts in 12 different emergency departments.  Some departments paid very little attention to patient satisfaction scores, and others had a near fanatical obsession with them.  I have been asked to hand out cards to patients on discharge and say to them, “remember, we strive for 5!”  AIDET scripting has been forced down my throat, and subsequently fallen to the wayside when nobody bought into the process.  I have had to have a meeting with my medical director over a poor Press Ganey survey that was an n = 1.  I am certain I have treated thousands of very happy patients relative to the incredibly small sample of Press Ganey surveys returned.  I have grown to hate the term “patient satisfaction.”

But, this is perhaps the biggest disclosure of all: I HAVE BECOME INFATUATED WITH THE PATIENT CARE EXPERIENCE.  I believe the term “patient care experience” is a more inclusive term that describes our technical expertise while also including everything else, such as communication, department ambience, throughput, and the behavior of everyone a patient comes into contact with while in the department. 

My goals with this post are the following:

1) Get to the crux of why providers dislike patient satisfaction

2) Review the literature out there

3) Debunk those articles which we use as a rally cry against patient satisfaction surveys

4) Discuss the key variables associated with survey scores

5) Suggest some very simple tips to bring back to your department that could help you tremendously

Before we move forward, I think we need to accept the following things.  First and foremost, an emphasis on the patient care experience is not going to go away, no matter how much we wish it would, and no matter how much we complain about it.  Instead of continuing to fight against it, we can focus on ways to proactively become part of the solution.  Our job is incredibly specialized and unique, so I understand the resentment that occurs when the experience of our patients is treated the same way a restaurant or retailer would treat the experience of their customers.  But I also know this; none of us out there would do this job for free.  Our compensation is important to us, and the money has to come from somewhere.  That money comes from seeing patients, and having them select our health care system over another one.  In the coming years, group and hospital reimbursement will become increasingly tied to the patient care experience, so I think it makes sense that the sooner we get on board with it the sooner we can come up with departmental solutions that are ready to maximize financial gains from this link.

We also need to wipe a few things from our mindset.  Our patients are not drug seeking, free-loading, non-paying, abusers of our system.  An overwhelming majority are normal people who are sick, injured, scared, or have nowhere else to turn. One of the noblest things we do is take care of patients when they have no other alternative.  Our patients have better places to be than in our emergency department, and they want to know that you recognize that.  Also, we need to stop internally thinking, or worse, saying out loud, “this is not an emergency, you shouldn’t have come here for this.”  Your patient does not have the medical knowledge or experience you have.  The average health care literacy in America is that of a 5^th grader.  They believe they need to see a doctor, and it’s our job to reassure them and make them better.  From a business standpoint, you need to change your state of mind.  These patients tend to be lower acuity, relatively easy dispositions, and are within the pool of patients most likely to get a Press Ganey survey.  As one of my partners used to say, “You don’t open a restaurant and hope nobody shows up.”

So why do providers hate this so much?  I think we all want to have happy patients and to be liked by them.  The biggest criticism is that patient satisfaction surveys are a poor attempt to measure a patient’s subjective perception of care with objective number scores.  As people of science, we are accustomed to critically reading research articles looking for bias and poor methodology.  It is natural to be frustrated when contract stability, financial incentive, and even individual job security is tied to poorly designed surveys with dreadfully small sample sizes.  Further disgust over the surveys lies in the fact that surveys only go to discharged patients – who are theoretically “less sick” – while leaving out admitted patients who we theoretically spent more time taking care of using the very skills we got into emergency medicine for.

There are other reasons I believe health care providers dislike such a heavy emphasis on patient satisfaction.  Some believe there are many factors beyond their control – experience with triage staff, transport, security guards, etc. are all going to affect a patient’s perception of their overall experience.  Attempts at scripting seem forced and sometimes condescending to the provider.  Perhaps the biggest complaint outside the poor survey design is a feeling that providers have to pander to their patients or even do things detrimental to a patient’s health in order to get strong scores – prescribing medication and ordering tests that are not medically indicated.

As my interest in the patient care experience has grown, I have read obsessively about it. Almost universally, opinion articles arguing and complaining about the use of patient satisfaction scores mention opiate prescriptions and harming patients within the first few paragraphs.  It is a crutch that providers lean on without actually knowing the literature. So let’s discuss the most important article on patient satisfaction.  It is important because I believe it is misunderstood, misquoted, and is not even a study on satisfaction in the emergency department.  However, it has a lot of buzzwords that can serve as a battle cry for those that are anti-patient satisfaction.  The article in question: The Cost of Satisfaction, published in the Archives of Internal Medicine in 2012 (Journal is now called JAMA of Internal Medicine).  In this study, they reviewed a prospective cohort of over 50,000 patients.  Medical data was extracted from the Medical Expenditure Panel Survey (MEPS) database, and these patients were asked customer satisfaction questions from the HCAHPS surveys.  When corrected for a number of potential confounding patient characteristics, the study found the following things to be statistically significant in patients that rated higher levels of satisfaction:

1) Emergency department visits dropped

2) Inpatient admissions increased (the correlation between this and #1 believed to be that more direct admits were done rather than sending patients through the ED or less satisfied patients bypassed their own doctors to go to the ED)

3) Higher health care and prescription drug expenditures (perhaps related to the increased hospital admission)

4) Increased patient mortality (the article states a 26% difference)

This study does raise very interesting points, but also has design flaws that make their conclusions suspect.  The study only evaluated patient satisfaction in the year 2000 (time 0 for the study).  They tracked mortality in years 1-6, but never actually rated a patient’s satisfaction during those times.  So, while they raise interesting points and topics for further debate, those that clutch to this study as a reason why patient satisfaction does not matter are foolishly doing so.  There are countless studies essentially refuting their points.  Physicians who have better communication and rapport with their patients typically have better patient compliance, lower malpractice suit risk, and report higher job satisfaction.

A second point that those who still resist patient satisfaction efforts rally around is the perception that to achieve higher scores, a provider must freely and recklessly dispense opiates.  I do not for a single second believe this to be accurate.  The perception that all of our ED patients are drug seeking is simply not true.  I have never felt pressured to give patient prescriptions for opiates (or any other medication for that matter) at the risk of poor scores if I did not.  No patient has ever threatened to give me a bad score if I did not give in to their demands.  A study out of UMass published in the 2014 Annals of Emergency Medicine suggests the same – that patient satisfaction lacks an association with dispensing opiates.  I will not deny that I have had patients come in with certain expectations – be it medications, testing, or consultations.  Instead of casting them off, I clearly communicated with them, managed expectations, and involved them in the decision making.  Not every encounter left either of us with a warm and fuzzy feeling inside, but we had a mutual respect for each other and they understood why I could not give them what they wanted on that day.

Simply put, patients care about the following things during their experience in the Emergency Department:

1) Communication

2) Perceived wait instead of actual wait

3) Feeling better – either reassurance or symptom relief

So what are some easy, incredibly effective, no cost ways that you the provider can take control of the patient care experience in your emergency department?

• Diffuse the wait – apologize for the delay and tell the patient their issue is important to you. Even if the door to doc time is 5 minutes, they will appreciate it and it will make your life easier.  If the LOS is significantly longer, it will relieve a lot of tension if they have been laying on a cot scared and feeling ill for a long period of time.
• SIT DOWN!! Multiple studies demonstrate that the patient and family think the physician was in the room twice as long as they actually were when they sit down
• Introduce yourself, including your role. Try to lay out why multiple people will come and ask the same things.  Think about how many times your patient may tell the same story – at a minimum they will speak to triage, nursing intake, med student, resident, and attending.
• Acknowledge the other people in the room – they know the patient much better than you do and often have valuable information for you. They want to be heard and they deserve to be heard.
• Give the patient time to state their issue. Ask an open ended question – and actually listen to the response.  Emergency medicine physicians take an average of 7 seconds to interrupt their patients.
• Give anticipated time frames – if you think a patient needs admission, tell them up front so they can plan accordingly. Overestimate times for diagnostic testing to return so when they come back sooner they are happy.  If a consultant is going to be involved and you know they are busy elsewhere, explain this to your patient.
• Round on your patients – if you’re walking by to another room, pop in real quick and remind them you have not forgotten about them. See if they need anything.  A MASSIVE DISSATISFIER IS NOT BEING KEPT IN THE LOOP ABOUT DELAYS AND ANTICIPATED DURATION OF STAY IN THE ED.
• Close the deal – when a patient is ready to be discharged, you need to go to the room to tell them they are being discharged. Do not print out a discharge and have the nurse walk into the room without the patient knowing the encounter is over.  It is very bad form, and will dissatisfy nursing staff and patient alike. This is an opportunity to make sure everything has been addressed and to remind them that your department is always here for them.  Make sure male patients and children have passed the “wife test” or the “mom test” and they are comfortable with discharge plan.  Trust me on this one!
• If you think it’s not fair to only include discharged patients in your surveys, create your own survey using an online survey tool, and place the link on a business card. Hand it to families of admitted patients. Now you have all encompassing data, and in my experience, you will get a larger sample size.  Administrators may not see this data regularly, but you will have access to it if you ever need to prove that you are doing better than Press Ganey suggests.

Everything I suggested is completely free.  It does not take an excessive amount of time.  All of them are likely to improve your interaction with the patient and make their experience in the ED better.  As a result, they will be more likely to comply with a treatment regimen that you lay out, and they are less likely to complain.  Shift your focus from a disdain for patient satisfaction, and instead focus on delivering a great patient care experience in your emergency department.  If you do so, the patient satisfaction scores will take care of themselves.  Excellent care and an excellent experience can and should go hand-in-hand.  We all need to strive to deliver a great patient experience every shift, every patient, every time.  As the provider, you set the tone for the rest of the department team.  The decision to change needs to start with you.

References / Further Reading

– “Patient Satisfaction.” An ACEP Emergency Medicine Practice Committee review paper.  June 2011.  www.acep.org/patientsatisfaction

– “Patient Satisfaction in Emergency Medicine.” Emergency Medicine Journal, 2004. 21:528-532; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1726409/pdf/v021p00528.pdf

– “Emergency Department Patient Satisfaction.” Family Practice Notebook, December 2014. http://www.fpnotebook.com/Manage/Cmnctn/EmrgncyDprtmntPtntStsfctn.htm

“Patient Satisfaction – Why Should We Care?” AAEM Young Physician Section article. May 2012. http://www.ypsaaem.org/yps-articles/past-yps-articles/2010/patient-satisfaction–why-should-we-care

– “AAEM Position Statement on Patient Satisfaction Surveys in the Emergency Department. May 2006. http://www.aaem.org/em-resources/position-statements/quality/patient-surveys

– “10 Easy Ways to Improve Customer Service in the Emergency Department.” ECI Healthcare Partners. http://www.ecihealthcarepartners.com/blog/patient-satisfaction-title-here/

– “Twenty Years of Patient Satisfaction Research Applied to the Emergency Department: A Qualitative Review.” American Journal of Medical Quality. Jan 2010 25:64-72 http://www.ncbi.nlm.nih.gov/pubmed/19966114

– “Boosting Patient Satisfaction in the Emergency Department: What Hospitals Should and Shouldn’t Do.” Becker’s Hospital Review. September 20, 2013. http://www.beckershospitalreview.com/hospital-management-administration/boosting-patient-satisfaction-in-the-ed-what-hospitals-should-and-shouldn-t-do.html

– “Patient Satisfaction in the Emergency Department. A Review of Literature and Implications For Practice.” Journal of Emergency Medicine. Jan 2004 vol 26 issue 1:13-26 http://www.ncbi.nlm.nih.gov/pubmed/14751474

– “Dying For Satisfaction.” Emergency Physicians Monthly. March 20, 2012. http://www.epmonthly.com/departments/columns/in-my-opinion/dying-for-satisfaction/

– “The Cost of Satisfaction.” Archives of Internal Medicine 2012; 172 (5): 405-411 http://archinte.jamanetwork.com/article.aspx?articleid=1108766

– “Lack of Association Between Press Ganey Emergency Department Patient Satisfaction Scores and Emergency Department Administration of Analgesic Medications.” Annals of Emergency Medicine. November 2014. Volume 64, (5): 469-481  http://www.annemergmed.com/article/S0196-0644(14)00120-6/abstract

– http://www.pressganey.com

– http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalHCAHPS.html