Put your efforts where your customers are — the emergency department
Service excellence in the ED improves bottom line
Your hospital’s emergency department (ED) probably touches more people in a year than any other department. If your hospital were a manufacturer, then your ED would be a retail store — it’s how people get to know you, how they form an image of your entire operation. Please them in the ED, and they will be your customers forever. Disappoint them, and they probably won’t come back no matter how diligently you’ve applied quality improvement to lab turnaround time or clinical processes.Improving customer service in the ED is also a hot topic for hospital administrators and managed care organizations (MCOs) that are aiming for better patient care, higher patient satisfaction ratings, and better ED performance indicators.
"Customer service is a major issue in health care in general now, but very few people are addressing it effectively," says Thom A. Mayer, MD, FACEP, chairman of the department of emergency medicine at Fairfax Hospital in Falls Church, VA. "Most of time, the attitude [in the ED] is that if somebody’s bad, you send them to a customer service course. Our philosophy is the complete opposite of that. We say customer service has to be built into the bricks and mortar of every operation."
Communication can untangle problems
At Fairfax Hospital, Mayer and his team determined the majority of complaints were coming from service transitions — when patients were moved from one area of the ED to the next. Staff and patients both were frustrated by the delays these hand-offs introduced.With the idea that good communication defuses the potential for frustration, Mayer’s team set to work. "We built fail-safes into those transitions by giving people a sense of how long it’s going to take," says Mayer. "If they wait longer, we make sure to say, I’m sorry you had to wait so long, but we’ll move you through as quickly as possible now.’"
In a busy ED, it is often difficult to ensure that patient input gets the audience it deserves. Mayer solved this by using his position as chairman to untangle the situation. "I encourage the Sam Walton [founder of Wal-Mart] approach," Mayer says. "He was notorious for going through the store aisles asking, How can we do this better?’ I walk from room to room, asking patients what problems they have, [and] if there’s anything we can do for them."
Letters from patients are copied to administrators and put in the proper employee’s personnel file. In fact, any source of concern, verbal or written, is brought to Mayer’s attention. "That makes people realize they’ll be held accountable for patient dissatisfaction and also for pleasing customers."
Other EDs also have wrestled with the patient satisfaction challenge. Telephone surveys rated patient satisfaction at Harris Methodist Hospital in Fort Worth, TX, at 3.45 on a scale of 4. When administrators challenged the ED to boost scores to 3.6 or higher, the solution wasn’t readily apparent.
"Our CEO had the vision that the ED is critical to our success and can touch more people in a year than any other department, so we need the highest satisfaction rates possible," says Lindy Rose, RN, BS, director of the hospital’s ED. "They set a high target for us, and we had to figure out a way to get to it."
It was easier said than done. "We struggled with many different methods that didn’t work," she says. These unsuccessful approaches included training staff in sensitivity, with several one-on-one sessions. "But those things didn’t impact our patient satisfaction score significantly."
Patient advocates handed out complimentary beverages to people in the waiting room during the busiest shift. "A nurse described a situation where the family had hot chocolate, the nurse had hot chocolate, but they’re both still waiting because the process isn’t good," she says. "The niceties’ we put on still didn’t fix the problem."
Focus groups criticize long waits
Next, focus groups were held with patients who had visited the ED in the previous six months. "That’s when we realized how much they truly hated going to the registration person before they were in a room," says Rose. "They talked a lot about the waits, and how they didn’t understand what they were waiting for." It became apparent that existing systems needed to be re-evaluated. "There was a big dissatisfaction with our process of doing triage, especially for people with low acuity who would usually go out to the lobby to wait until a room was available," says Rose.After concluding that hotel-like amenities and surface niceties didn’t make patients happier, Harris Methodist created a panel to address the more substantial patient-specific frustrations that can come with ED visits.
"We decided that for the amount of changes we needed to make, we needed a united front with all heads around the table," she says. A joint practice council was formed, which included doctors, nurses, clerks, labs, technicians, and patient advocates. About 40 of the 60 resulting brainstorming ideas were implemented.
"Anything you change impacts more people than you ever imagine," explains Rose. "It was wonderful to have all those people right there at the table to tell us right then and there how something would affect them."
Two major initiatives evolved from these sessions:
• Registration clerks now come to patients’ rooms, eliminating a source of waiting, confusion, and frustration for patients.
• Minor problems have a fast track. To reduce waiting time for all patients — both low and high acuity — the staff created a fast track for low acuity patients who wanted to be taken care of quickly and whose problems demanded less time to treat.
As a result of these and other changes, patient satisfaction scores rose rapidly. For the last quarter of 1996, they were at an all-time high of 3.66. "At one time, I would have told you we couldn’t reach that," Rose says. "But we are continually tweaking things. We hope to sustain that and even see a slow rise." The average stay for all ED patients fell from 162 to 132 minutes, and time waiting to see a physician dropped from 52 to 10 minutes.
A newsletter was created at Harris Methodist to keep staff apprised of progress, with a detailed report from the joint practice council. "People read every page of it and really look forward to it," she says.
Measure your success
What about after you have made strides toward ensuring customer satisfaction? How do you let people know how far you’ve come? How can you demonstrate to administrators and MCOs that your ED is superior? To accomplish these ends, information systems should be in place to gather data that will showcase the fruits of your labor."We have to start connecting customer service to the bottom line," says Richard Salluzzo, MD, FACEP, former chairman of the department of emergency medicine and current associate dean and president of faculty practice at Albany (NY) Medical Center. Presenting administrators with hard data on customer service scores is a smart tactic when negotiating. "Going to them with plans that cost money with that data as a backdrop is very effective," says Salluzzo. It also will improve their perception of satisfaction with your overall performance in the ED, he adds.
Hard numbers motivate staff
At Harris Methodist, chart audits were done internally to track progress. "It was one of the hardest things, because everyone is so busy the last thing you want to do is some tedious number-crunching," says Rose. "But had we not done the initial study to know what our baselines were and monitored it religiously every month, I wouldn’t have been able to prove that what we did had any impact."Getting those hard numbers can go a long way toward motivating staff and impressing administrators. "When the intervention occurred, we went from 2.5 to 0.4 letters of complaint per 1,000 [patients]," says Mayer. "We actually have more letters of compliment than complaint now, which is very unusual in an ED."
A side benefit is that patient perception of all aspects of ED service tends to improve after customer service efforts are implemented. "One of our studies showed that the skill of the doctors, the doctor’s ability to explain diagnosis, and perception of waiting time all improved," says Mayer. "What’s interesting is we didn’t hire any more doctors, and our doctors are no better than before, yet [patients] rate our skill higher."
Once you’re able to prove satisfaction has increased, the results can be used as a bargaining tool with MCOs. "We have several managed care plans that we’ve shown this data to, that now contract exclusively with us," says Mayer. "So the customer service improvement wasn’t just of clinical advantage to us, but strategic advantage from a contracting standpoint."
[For more information, contact: Thom Mayer, chairman, department of emergency medicine, Fairfax Hospital, 3300 Gallows Road, Falls Church, VA 22042-3300. Telephone: (703) 698-1110.
Lindy Rose, director, emergency department, Harris Methodist Hospital, 1301 Pennsylvania Ave., Fort Worth, TX 76104. Telephone: (817) 882-2000.
Richard Salluzzo, associate dean and president of faculty practice, Albany Medical Center, 43 New Scotland Ave., Albany, NY 12208. Telephone: (518) 262-3125.]
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