Emergency department patient satisfaction Essay
Emergency department patient satisfaction
Customer service initiatives in healthcare have become a popular way of attempting to improve patient satisfaction. The effect of clinically focused customer service training on patient satisfaction in the setting of a 62,000-visit emergency department and level 1 trauma center is investigated. The most dramatic improvement in the patient satisfaction survey came in ratings of skill of the emergency physician, likelihood of returning, skill of the emergency department nurse and overall satisfaction. These results suggest that such training may offer a substantial competitive market advantage, as well as improve the patients’ perception of quality and outcome. A practitioner’s response to the case study is also included. Customer service initiatives in healthcare have become a popular way of attempting to improve patient satisfaction. The effect of clinically focused customer service training on patient satisfaction in the setting of a 62,000-visit emergency department and level 1 trauma center is investigated. The most dramatic improvement in the patient satisfaction survey came in ratings of skill of the emergency physician, likelihood of returning, skill of the emergency department nurse and overall satisfaction. These results suggest that such training may offer a substantial competitive market advantage, as well as improve the patients’ perception of quality and outcome. A practitioner’s repsonse to the case study is also included.
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visit emergency department and level I trauma center. Analysis of patient complaints, patient compliments, and a statistically verified patient-satisfaction survey indicate that (1) all 14 key quality characteristics identified in the survey increased dramatically in the study period; (2) patient complaints decreased by over 70 percent from 2.6 per 1,000 emergency department (ED) visits to 0.6 per 1,000 ED visits following customer service training; and (3) patient compliments increased more than 100 percent from 1.1 per 1,000 ED visits to 2.3 per 1,000 ED visits. The most dramatic improvement in the patient satisfaction survey came in ratings of skill of the emergency physician, likelihood of returning, skill of the emergency department nurse, and overall satisfaction. These results show that clinically focused customer service training improves patient satisfaction and ratings of physician and nurse skill. They also suggest that such training may offer a substantial competitive market advantage, as well as improve the patients’ perception of quality and outcome.
Recent changes in healthcare have led to increasing competition and the perceived commercialization of the healthcare provided to patients. At the same time, a need for reaffirmation of the importance of the patient-physician relationship has been expressed in the midst of such powerful forces (Laine and Davidoff 1996; Glass 1996; Pellegrino and Thomasma 1989). One aspect of the patient-physician relationship deserving further study is the role of customer service training in healthcare. While numerous customer service training tools exist in business and industry, no studies have clearly delineated the efficacy of customer service training for patients in a clinical setting. This study examines the effect of a required customer service training program taught by healthcare professionals on patient and family complaints, compliments, and satisfaction in a high-volume high-acuity emergency department.
All patients presenting to the Emergency Department at Inova Fairfax Hospital, Falls Church, Virginia, between May 1, 1994 and April 30, 1995 formed the control group, representing the period prior to emergency department customer service training. Patients presenting to the emergency department between May 1, 1995 and April 30, 1996 formed the study group, representing the period following customer service training intervention. The mechanism of patient complaint/compliment analysis and the survey criteria were identical in the control and study periods. Patient acuity was assessed by three measures: the number and percentage of patients admitted to the hospital; the number and percentage of patients with Current Procedural Terminology 1996 (CPT) evaluation and management (E/M) codes 99281-99285, (Kirschner et al. 1996); and a nursing acuity rating scale (EMERGE, Medicus Systems, Evanston, Illinois). Inova Fairfax Hospital is a 656-bed not-for-profit institution that is a teaching hospital, regional referral center, and level I trauma center.
Customer Service Training
All emergency department staff involved in patient contact (physicians, nurses, ED technicians, registration personnel, core secretaries, social workers, ED radiology, and ED respiratory therapy) were required to attend an eight-hour customer service training program. The numbers and types of staff involved in training are listed in Table 1. Because of logistic limitations, emergency medicine residents attended a focused fourhour required training course. The eight-hour program consisted of the following modules: basic customer service principles, recognition of patients and customers (Are they patients or customers?), service industry benchmarking leaders, stress recognition and management, communication skills, negotiation skills, empowerment, customer service proactivity, service transitions, service fail-safes, change management, and specific customer service core competencies. (More detailed information on the content of these modules is listed in Appendix 1.) These core competencies follow: making the customer service diagnosis (in addition to the clinical diagnosis) and providing the right treatment; negotiating agreement resolution of patient expectations; and building moments of truth into the clinical encounter.
Following the initial required training, new physicians or ED employees were required to attend identical customer service training within four months of their initial employment. Additional mandatory customer service training updates were offered three times per year and included modules of conflict resolution, customer service skill updates, advanced communication skills, and assertiveness training.
Patient Satisfaction Data
Patient satisfaction data in both the control and study groups consisted of patient complaints, patient compliments, and a telephone patientsatisfaction survey conducted by an independent research firm (Shugoll Associates, Rockville, Maryland) that was blinded to the study hypothesis and course content. Patient complaints and/or compliments were systematically identified from all available means, including verbal, written, telephone, or electronic mail sources. Sources of patient complaints, data analysis, and categorization of complaints were identical in the control and study groups, which was coordinated by hospital quality improvement analysts. ED staff were instructed to report all potential complaints and concerns, regardless of how minor, to appropriate physician or nurse managers in both the control and study periods.
Complaints were logged into a central office and were investigated initially by three authors (TM, RC, DR). In cases where classification of type of complaint differed, additional information and/or clarification was sought from staff, patients, and family. Any discrepancies were resolved by group-consensus techniques. All complaints and the classification thereof were independently reviewed and verified by quality-improvement analysts. Patient complaint and compliment letters were referred for comment or clarification to appropriate ED staff in both the control and study periods.
Outpatient satisfaction surveys were conducted by an independent research firm (completely blinded to the study and its hypothesis) utilizing a 50-item questionnaire to identify key factors in customer satisfaction. This survey instrument was validated on a sample of more than 3,000 patients prior to implementation in either the control or study group. The study used a telephone survey on a randomized number table basis to 100 ED outpatients per quarter (Appendix 2). Logistic regression analysis performed on these data identified 14 areas of more important/key attributes in the ED (see Table 2). Patient compliment and complaint data, as well as acuity data, were subjected to a two-tailed ttest and the Fisher Exact test. Patient satisfaction surveys were subjected to a two-tailed t-test with a 95 percent confidence level.
Patient Turnaround Times
Patient turnaround times (TAT) were calculated from time of initial arrival in the ED to either discharge or transfer to an inpatient unit. Turnaround times were routinely calculated on each patient and on an aggregate basis by day, month, quarter, and year.
Neither ED volume nor acuity changed to a statistically significant degree between the control and study periods, based on both admission percentage and nursing acuity (see Table 3). Analysis of CPT 96 Evaluation and Management Codes showed a statistically significant increase in codes 99283 and 99285, with a similar decrease in codes 99281 and 99284. The number of pediatric patients did not change in a statistically significant fashion during the study period. The only payor mix category to rise in a statistically significant fashion was managed care (p < .01), with a nearly identical decrease in commercial insurance. Neither compliments nor complaints correlated with payor category.
Patient Turnaround Time
Mean patient turnaround time dropped from three hours and 24 minutes (204 minutes) to three hours and seven minutes (187 minutes), but this difference was not statistically significant, nor did the percent of patients at one and two standard deviations from the mean change in a statistically significant fashion. Patient Compliments The total number of patient compliments rose from 69 in the control period to 141 in the study period, an increase of more than 100 percent (p < .00001) (see Table 3). Patient compliment letters consistently mentioned warmth, compassion, and skill of the emergency care provider as the reason for contacting management to praise the ED staff. There was no statistical difference between males and females among patient compliments. Patient Complaints
Patient complaints dropped from 153 in the control period (2.5 complaints per 1,000 ED visits) to 36 in the study period (0.6 complaints per 1,000 ED visits), (p < .00001) (see Table 3). Complaints about perceived rudeness, insensitivity, or lack of compassion on the part of ED staff dropped most dramatically. Two-thirds of complaints in the study period were a result of waiting times, billing, or delays in obtaining an inpatient bed, compared to 30 percent in the control period. Nevertheless, complaints regarding waiting times, billing, and wait time for an inpatient bed still decreased 50 percent in the study period (p < .001). There were no significant differences in patient complaints based on age or sex, confirming results of the study by Hall and Press (1996).
Patient Satisfaction Survey Data
Baseline survey data were subjected to logistical regression analysis that indicated that 14 surveyed areas formed a core group of key satisfaction attributes. All of these 14 attributes showed increases in the study period (p < .001, see Table 2). The largest increases were in the following areas: skill of the emergency physician, skill of the nurse, likelihood of returning, overall quality of medical care, doctor’s ability to explain condition, diagnosis, and treatment options, and triage nurse’s sensitivity to pain.
The patient-physician and patient-nurse relationships are arguably the oldest in the history of medicine. These relationships have recently been described as being under siege because of an increase in the tension between the art and science of medicine, as well as the strains attendant to changes in the economic structure of healthcare (Glass 1996). To this list may be added a third causative factor: the lack of rigorous, formal training for healthcare professionals in the customer service fundamentals of the patient-provider relationship.
The fundamentals of such training are closely tied to what has traditionally been described as the art of medicine or the concept of beneficence (Pellegrino and Thomasma 1989). Physicians have for the most part learned appropriate patient interaction skills through observing their mentors and peers during the course of graduate medical education. However, there has only recently been substantial study of this important subject (Buller and Buller 1987; Aharony and Strasser 1993).
While customer service has been emphasized in American business and industry in recent years (Zeithamal, Parasuraman, and Berry 1990; Jones and Sasser 1995; Reichheld 1996; Berry and Parasuraman 1991; Berry 1995), few training modules are specifically targeted toward physicians and healthcare professionals. For this reason, the authors created an eight-hour customer service training course for their ED providers, based on principles of adult education, benchmarks from the customer service industry (Sanders 1995; Spectre and McCarthy 1995; Carlzon 1987; Connelan 1997), experience in the clinical setting, and the existing literature on patient satisfaction (Pelligrino and Thomasma 1989; Thompson and Yarnold 1995; Thompson et al. 1996; Bursh, Beezy, and Shaw 1993; Rhee and Bird 1996; Dansk and Miles 1997; Hall and Press 1996; Eisenberg 1997). This literature emphasizes the importance of communication skills, managing information flow, actual versus perceived waiting times, and the expressive quality of physicians and nurses. All of these concepts were built into the training modules, including practical clinical examples of behaviors reflecting these and other concepts.
Our philosophy in designing this course was simple. Customer service is a skill for which we hold our staff accountable but in which they had never formally been trained. We believed that this dilemma required, at a minimum, two sentinel events to occur. First, the department needed to have a clearly articulated and easily understood cultural transformation to a solid commitment to customer service. Second, staff members needed education in a practical, pragmatic fashion regarding precisely how such customer service principles could be applied in the clinical setting. Just as advanced cardiac life support, advanced trauma life support, and pediatric advanced life support courses can be used to improve cardiac, trauma, and pediatric resuscitation, respectively, we believed customer service outcomes could be improved by well-designed, mandatory, rigorous application of customer service training.
The training was provided by active clinicians involved in day-to-day patient care activities (TAM, RJC). We believe this clinical credibility may have played an important part in the customer service transformation, inasmuch as the staff knew the trainers were well aware of the inherent problems of applying pragmatic customer service skills in a busy emergency department.
The data from this study strongly support the hypothesis that clinically based, formal customer service training grounded on these principles can dramatically decrease patient complaints, increase patient compliments, and improve patient satisfaction, at least in a high-volume, high-acuity ED. Patient complaints dropped by over 70 percent and compliments more than doubled during the study period, such that patient compliments actually exceed complaints in our 62,000 patient visit emergency department and level I trauma center. National data indicate that ED complaints average between three to five per 1,000 emergency department patients, although no data are available regarding rates of patient compliments (Culhane and Harding 1994). Our emergency department was slightly below that national standard level even during the control period.
Analysis of the patient satisfaction survey data revealed an extremely important trend. Specifically, patients rated skill of the emergency physician, overall quality of medical care, and skill of the ED nurse as three of the most improved areas during the study period compared to the control period, despite the fact that there were no changes in the ED physician staff during the study and there was very little turnover among ED nurses. This strongly implies that patients rate the quality of care and the skill of the physician and nurse based on elements of the customer service interaction. These data suggest an important causal relationship between the technical component of care and the patient caregiver interaction, which has not been previously demonstrated. It is important to recognize that both customer service and technical skills are competencies to which hospitals and healthcare systems should hold their staff accountable on a daily basis. Hospitals spend substantial dollars to ensure that their staffs are technically competent to deliver quality medical care (Herzlinger 1997). However, to ensure that customer service is effective, clinically based customer service training is essential to give staff the appropriate skills in the clinical setting to deliver service competently.
This concept is indirectly supported by data from Mack and colleagues (1995), who found that satisfaction with interactive aspects of emergency medical care produced higher correlations with measures of future intention to use the service than did satisfaction with medical outcomes themselves. Their study, however, did not undertake interventions to improve the interactive, communicative aspect of healthcare in that setting. Similarly, Smith and colleagues (1995) evaluated the effect of a four-week training program, focusing on patient interviewing, somatization, patient education, and self-awareness, that was taught to first year internal medicine and family practice residents. Their data were not conclusive, but suggested that some but not all aspects of patient satisfaction could be improved by such training. This study tends to confirm the work of Thompson and colleagues (1996) that demonstrated in a much smaller sample size that expressive quality and management of information flow to the patient had an effect on patient satisfaction. However, their study did not assess the impact of strategies and techniques for ED staff to improve patient satisfaction by improving expressive quality.
While several studies (Thompson et al. 1996; Thompson and Yarnold 1996; Dansk and Miles 1997; Hall and Press 1996) have emphasized the importance of waiting time and exceeding patient expectations regarding length of waiting time, our study demonstrates a dramatic improvement in patient satisfaction without a statistically significant reduction in patient turnaround time. This supports the work of Bursch and colleagues (1993), who found in a study of 258 patients that the five most important variables for patient satisfaction were the amount of time it took before being cared for in the ED, patient ratings of how caring the nurses were, how organized the ED staff was, how caring the physicians were, and the amount of information provided to the patient and family. However, the study did not assess strategies to improve satisfaction based on this knowledge. All of this information was built into the training modules to assist staff with practical strategies to manage waiting time effectively using information flow, queuing theory, and verbal skill training.
The implications of the higher ratings of the skill of the emergency physicians and nurses are intriguing and could have a far-reaching impact on healthcare. Perhaps the strongest implication is that perceived skill stands as a marker for quality and/or outcome in the mind of patients and their families. It has been shown repeatedly that patient compliance increases with confidence in the physician (Frances, Korsch, and Morris 1969; Sharfield et al. 1981; Waggoner, Jackson, and Kern 1981; Schmittdiel et al. 1997). While our study did not directly assess improvements in outcome, quality of care, or appropriateness of care, it certainly appears that patients rated the skill of the healthcare providers as a key quality characteristic in this survey. Furthermore, the fact that ratings of quality of medical care and likelihood of returning also increased dramatically speaks to the importance that effective customer service training may have in offering a competitive market advantage to hospitals and healthcare institutions. This is particularly important as the concept of customer loyalty is closely tied to the likelihood of a patient or their family returning to that healthcare institution. As the focus on outcomes management and evidence-based medicine increases, it is important to take into account the effect that customer service skills have on patients’ perceptions of quality and outcome.
This study may be subject to several criticisms. First, while statistical data on patient compliments and complaints obtained substantial statistical significance, the number of patients contacted for the outpatient satisfaction telephone survey may have resulted in sampling bias. While a larger sampling is planned in the future, the patient satisfaction survey data trends were consistent throughout all quarters and appear to be a valid statistical tool, despite the number of patients sampled. Second, it was not possible to blind those responsible for investigating and classifying complaints and compliments. However, we did attempt to reduce or eliminate possible reporting or observer bias by identifying complaints from all sources and ensuring that all complaints and their classification were reviewed and approved by an author who was not involved in ED operations and by quality improvement analysts. Third, information is not available on national or regional trends of patient complaints and/or satisfaction during the study period. It is possible that the data in this study may reflect local, regional, or national trends toward decreased complaints and increased satisfaction, either globally throughout healthcare or in ED patients specifically.
However, this is highly unlikely as no such trends have been previously reported, nor would such trends fully explain the data from this study, even if they were present. The data on patient acuity indicated an increase in CPT codes 99283 and 99285, suggesting a slight trend toward higher patient acuity. This could mean that patients with higher levels of acuity are more satisfied and less likely to complain. No data are available to either prove or disprove this possibility, but the trend toward higher acuity would not appear to completely explain the dramatic improvement seen in this study. Furthermore, the patient-satisfaction telephone survey excluded inpatients, who comprise a larger percentage of patients in the 99285 service code. Further study is needed to delineate the relationship of ED patient acuity to satisfaction.
Despite these potential limitations, this study demonstrates that clinically based customer training for ED staff can decrease patient complaints and increase patient satisfaction in a large volume, high-acuity ED, and that satisfaction is independent of patient turnaround times. Furthermore, the data support the concept that patients rate the skill of the emergency physician, overall quality of medical care, and skill of the ED nurse significantly higher after such training is provided to the ED staff. Additional studies in ED with different volumes, acuities, and geographic locations are needed to demonstrate whether these results can be duplicated. Studies of the impact of customer service training in other healthcare settings would also be of benefit. Nonetheless, clinically focused customer service training has been shown in this study to improve patient satisfaction and ratings of the skill of physicians and nurses. If verified by other studies, customer service training should be considered an important part of graduate and undergraduate medical education to improve both the art and science of the patient-physician relationship.
The clinically based customer service training described in this study is now a required part of competency based orientation for all physicians, nurses, residents, and support staff in the emergency department. All professional and non-professional staff interviewed for positions in the emergency department are advised of the institution’s strong commitment to customer service training and the necessity of attending the required training course. As healthcare increasingly emphasizes accountability for customer service in its staff, it is increasingly important that practical and
effective customer service training is provided.
While not directly addressed in this study, the data on ratings of quality of medical care, skill of the physician and nurses, and likelihood of returning strongly suggest that effectively completing the customer service transition offers a competitive market advantage to hospitals and healthcare systems.
Aharony, L., and S. Strasser. 1993. “Patient Satisfaction: What We Know About and What We Still Need to Explore.” Medical Care Review 50 (1): 49-79. Berry, L. L. 1995. On Great Service: A Framework for Action. New York: Free Press. Berry, L. L., and A. Parasuraman. 1991. Marketing Services: Competing Through Quality. New York: Free Press. Butler, M. K., and D. B. Buller. 1987. “Physician’s Communication Style and Patient Satisfaction.” Journal of Health and Social Behavior 28 (4): 375-88. Bursh, B., J. Beezy, and R. Shaw. 1993. “Emergency Department Satisfaction: What Matters Most?” Annals of Emergency Medicine 22: 586-91. Carlzon, J. 1987. Moments of Truth: New Strategies for Today’s Customer-Driven Economy. New York: Ballinger Publishing.
Connelan, T. 1997. Inside the Magic Kingdom. Austin, TX: Bard Press. Culhane, D. E., and P. J. Harding. 1994. “Quality in Customers: Great Expectations.” Presented to the American College of Emergency Physicians Management Academy, Boston, Massachusetts, May 19, 1994. Dansk, K. H., and J. Miles. 1997. “Patient Satisfaction with Ambulatory Healthcare Services: Waiting Time and Follow-up Time.” Hospitals and Health Services Administration 42 (2): 165-77. Eisenberg, B. 1997. “Customer Service in Healthcare.” Hospitals and Healthcare Services Administration 42 ( 1 ): 17-32.
Frances, V, B. M. Korsch, and M. J. Morris. 1969. “Gaps in Doctor-Patient Communication. Patient’s Response to Medical Advice.” New England Journal of Medicine. 280: 535-49. Glass, R. M. 1996. “The Patient-Physician Relationship: JAMA Focuses on the Center of Medicine.” Journal of the American Medical Association 275: 147-48. Hall, M. F., and I. Press. 1996.
“Keys to Patient Satisfaction in the Emergency Department: Results of a Multiple Facility Study.” Hospitals and Healthcare Administration 41 (4): 515-32. Herzlinger, R. 1997. Market-Driven Health
Care. New York: Free Press. Inova Health System. 1997. “Outpatient Satisfaction Research.” Shugoll Research. Rockville, MD. Jones, T. O., and W. E. Sasser, Jr. 1995. “Why Satisfied Customers Defect.” Harvard Business Review 73: 88-99. Kirschner, C. G., R. C. Burkett, G. M. Kotowicz, et al. 1996. Physicians’ Current Procedural Terminology-CPT 96, ed 5. Chicago: American Medical Association. Laine, C., and F. Davidoff. 1996. “PatientCentered Medicine: A Professional Evolution” lournal of the American
Medical Association 275: 152-56. Mack, J. L., K. M. File, J. E. Horwitz, and R. A. Prince. 1995. “The Effect of Urgency on Patient Satisfaction and Future Emergency Department Choice.” Health Care Management Review 20: 7-15. Pellegrino, E. D., and D. C. Thomasma. 1989. For the Patient’s Good: The Restoration of Beneficence in Health Care. New York: Oxford University Press. Rhee, K., and J. Bird. 1996. “Perceptions in Satisfaction with Emergency Department Care.” Journal of Emergency Medicine 14: 679-83.
Reichheld, E E 1996. “Learning from Customer Defections.” Harvard Business Review 74: 56-69. Sanders, B. 1995. Fabled Service: Ordinary Acts, Extraordinary Outcomes. San Diego: Pfeiffer and Company. Schmittdiel, J., J. V. Selby, K. Grumbach, and C. P. Quesenberry. 1997. “Choice of a Personal Physician and Patient Satisfaction in a Health Maintenance Organization.” Journal of the American Medical Association 278 (19): 1596-1612. Sharfield, B., C. Wray, K. Hess, and E. M. Smith. 1981. “The Influence of Patient-Practitioner Agreement on Outcome of Care.” American Journal of Public Health 71: 127-31. Smith, R. C., J. S. Lyles, J. A. Mettler, et al. 1995. “A Strategy for Improving Patient Satisfaction by the Intensive Training of Residents in Psychosocial Medicine: A Controlled, Randomized Study” Academic Medicine 70: 729-32. Spectre, R., and P. D. McCarthy. 1995. The Nordstrom Way: The Inside Story of America’s #1 Customer Service Company. New York: John Wiley and Sons.
Thompson, D. A., P. R. Yarnold, D. R. Williams, and S. L. Adams. 1996. “Effects of Actual Waiting Time, Perceived Waiting Time, Information Delivery, and Expressive Quality on Patient Satisfaction in the Emergency Department” Annals of Emergency Medicine 28: 657-65. Thompson, D. A., and P. R. Yarnold. 1995. “Relating Patient Satisfaction to Waiting Time Perceptions and Expectations: The Disconfirmation Paradigm.” Academic Emergency Medicine 2: 1057-62. Thompson, D. A., P. R. Yarnold, S. L. Adams, and A. B. Spaccone. 1996. “How Accurate Are Waiting Time Perceptions of Patients in the Emergency Department?” Annals of Emergency Medicine 28: 652-56. Waggoner, D. M., E. B. Jackson, and D. E. Kern. 1981. “Physician Influence on Patient Compliance: A Clinical Trial.” Annals of Emergency Medicine 10: 348-52. Zeithamal, V. A., A. Parasuraman, and L. L. Berry. 1990. Delivering Quality Service: Balancing Customer Perceptions and Expectations. New York: Free Press. You have requested “on-the-fly” machine translation of selected content from our databases. This functionality is provided solely for your convenience and is in no way intended to replace human translation. Show full disclaimer Neither ProQuest nor its licensors make any representations or warranties with respect to the translations. The translations are automatically generated “AS IS” and “AS AVAILABLE” and are not retained in our systems. PROQUEST AND ITS LICENSORS SPECIFICALLY DISCLAIM ANY AND ALL EXPRESS OR IMPLIED WARRANTIES, INCLUDING WITHOUT LIMITATION, ANY WARRANTIES FOR AVAILABILITY, ACCURACY, TIMELINESS, COMPLETENESS, NON-INFRINGMENT, MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. Your use of the translations is subject to all use restrictions contained in your Electronic Products License Agreement and by using the translation functionality you agree to forgo any and all claims against ProQuest or its licensors for your use of the translation functionality and any output derived there from. Hide full disclaimerTranslations powered by LEC. Translations powered by LEC.