Clinical prowess does not guarantee good patient satisfaction scores
Here’s how QI can help you have both
How would you like to find out that your clinically renowned emergency department (ED) ranks close to the bottom in patient satisfaction? Such was the predicament at Overlook Hospital in Summit, NJ. Both the American Hospital Association and the Health Care Financing Administration use Overlook’s ED time to thrombolytic treatment for myocardial infarction as a national benchmark. But clinical excellence made no difference in patient satisfaction. Ratings were in the 26th and 18th percentiles for the second and third quarters of 1996.
Still, looking at clinically sound emergency care such as Overlook’s might tempt a devil’s advocate to ask why a hospital should pour additional resources into ED patient satisfaction when so many inpatient functions need fixing. And don’t people spend most of their hospital time as inpatients? The Overlook staff respond by pointing out that patient satisfaction improvements are not only good for consumers and providers, but they carry over to other hospital functions as well.
James Espinosa, MD, FACEP, director of the ED, describes the department as a proving ground of how process improvements should integrate with each other. "If the ED and other functions in a health care system can learn how to integrate, the techniques can transfer to other functions. Patient satisfaction is a real outcome, but it’s a by-product of dependencies among different functions of the health care system." It’s a more compelling driver of clinical cooperation than cost reduction, he adds.
And, says Linda Kosnik, RN, MSN, CEN, nurse manager of Overlook’s ED, patient satisfaction is more than being nice to people.
Matching satisfaction to medical excellence
As soon as the shock of low patient satisfac -tion ratings receded in late 1996, Espinosa called a Patient Satisfaction Summit for ED staff. Brain storming groups consisted of technicians, support staff, nurses, physicians, and volunteers. Among the areas addressed were these:
- helpfulness at registration;
- technical skill of nurses;
- wait time to see a doctor;
- courtesy of ED staff toward family and friends of patient;
- concern for patient’s privacy.
Each of those areas appears on patient surveys mailed out by Press, Ganey Associates Inc., a South Bend, IN-based firm specializing in assessment and enhancement of patients’ health care experiences. Overlook Hospital engaged the firm to consult on improving patient satisfaction throughout the facility.
After the brainstorming phase, ED staff segmented their work into three cycles like those used in their clinical improvement projects:
1. Time-to-decision — patient arrival, X-ray, or other diagnostic tests, and care plan.
2. Time-to-admission — decision to admit to inpatient bed assignment.
3. Time-to-bed — wait for transfer to inpatient unit.
Results prove the validity of the three-cycle breakdown. By the time the second Patient Satisfaction Summit convened in early 1998, 70% (56) of the 80 ideas generated from the first one were in place.
It’s not individuals who make or break patient satisfaction ratings but the processes that go into a patient’s experience at each encounter with the delivery system. If the ED staff control all the processes that feed into their patient satisfaction standings, improvements would have been easier. But gains depended on interdepartmental cooperation and mutual understanding of very different frames of reference.
For example, the time unit for bed turnover in the ED is minutes, but on inpatient floors, it’s days. "Our actual capacity for seeing patients was reduced when we held patients in our beds for three to six hours waiting for admission to inpatient beds," recalls Kosnik.
Delays originated in ED, too
Yet an interdepartmental improvement team found delays on both sides.
The inpatient floors had backups as patients transferred in from surgery, catheter lab, and the admissions department. The ED staff sometimes got busy and failed to send newly-admitted patients’ orders to the inpatient units.
The interdepartmental solutions include:
- A pneumatic tube system transmits patient orders from ED to inpatient units.
- A standard patient assessment and order form serves the ED as well as inpatient units.
- The ED manages bed control. Kosnik volunteered for the job during an interdepartmental team rehash of the job’s aggravations. As the "czarina of bed control," she explains, "The floors have 15 minutes to make bed assignments. If not, we do it." To expedite bed turnover, the registration and housekeeping functions have been decentralized to each floor. "This means there are fewer people to deal with at each point of the process," observes Kosnik.
- X-ray cycle times were cut. "Patients reported on their Press, Ganey surveys that they want to be out of the ED in 60 minutes, but that was impossible until we re-engineered our X-ray cycles from 74 minutes to 20 minutes," Espinosa says. Interventions: Streamlining film collection steps and installing an alternator in the ED to facilitate X-ray viewing. Attending physicians especially appreciate the fast X-ray turnaround. And the .3% false-negative read rate complies with Overlook’s standard baseline.
- The fast-track section reserves three beds for problems that don’t require X-rays and can be treated in less than 60 minutes — for example, sprained ankles, cuts, or abrasions.
Paradoxically, Espinosa finds that ED arrival-to-discharge cycles can be too fast. Patients say they feel rushed through Overlook’s most rapid discharge cycles of 30 minutes. The present in-and-out average of 47 minutes seems about right, he adds. (For more details, see related story, "Teams pull emergency services out of the doldrums," at right.)
Minutes and single points count heavily
It took two years for the department’s ratings to climb from 77.1 to 82.8. The scores represent improvement on some 30 satisfaction items in Press, Ganey’s mail-back patient surveys. When a department moves one point, each staff member is involved in the improvement, observes Irwin Press, PhD, co-director of Press, Ganey. "To move an entire emergency department up even one-half of a point would be significant," he adds. Overlook’s five-point jump in two years is especially remarkable when you understand that there is a mere 13 to 14 point spread among all the EDs that use Press, Ganey scales.
Recently, Overlook ED won one of the six Press, Ganey 1998 Client Success Story awards. "Their improvement was not an overnight thing. We like to see steady improvement, not the one-shot increases," Press comments.
Espinosa adds that ratings went from the 95th percentile in first quarter of 1998, when the contest scores were calculated, to the 99th percentile in May and June 1998.
Myth-breaking data about EDs
Turning to the debate surrounding costs and appropriate use of EDs, a widely held opinion that emergency care is often used inappropriately feeds many initiatives intended to divert consumers toward "more cost-effective" care venues. But Espinosa says he sees it differently. "Hospitals have to keep their emergency departments open anyway," so why not use them as effectively as possible? "Patients have the sense of physician availability at emergency departments, they know they can get an X-ray there, and EDs are convenient. So despite our attempts to not resource them, patients will use them."
He cites a study which is "triggering a revolution in the way ED visits are regarded.1 In it, the investigator, Robert Williams, MD, DrPH, states, "There is very little marginal or extra cost to squeeze in [the case of] a 12-year-old patient with acute asthma at a private physician’s office at 4:00 in the afternoon. At 4:00 in the morning, however, the marginal cost of a visit to a physician’s office by the same patient with asthma would be very high because of the inconvenience and expense of opening the office at a time when it is normally closed. In contrast, the marginal cost of seeing a patient with asthma in the emergency department at 4 a.m. is small, because the early morning is usually a slack period, yet the emergency department remains completely staffed."
Hospitals tend to load the ED up with charges that aren’t entirely theirs, Espinosa notes. Sup porting his point, Williams’ study of 24,010 ED visits in Michigan reveals that the average cost was 55% of the average charge. The true costs of nonurgent care in the ED are relatively low, he contends. "The potential savings from a diversion of nonurgent visits to private physician’s offices may therefore be much less than is widely believed," writes Williams.
It’s those nonurgent visits — especially by insured consumers — that Kosnik says would enhance health care delivery by creatively engaging the ready resources of hospital EDs. "The nonurgent care patients are the ones we would like to see, the ones who go to the doc-in-the-box’ and pay out of pocket."
The reason many insured consumers turn to those ambulatory centers, she says, is that "managed care isn’t doing what it should be doing for patients. It makes it difficult to get doctor appoint ments. That’s why our volume continues to go up." Indeed, Overlook’s volume is up 10% in the past three years.
Is it time to diversify emergency services?
"We think we could take care of those nonurgent patients very effectively in our Fast Track, but because of managed care, they may choose other facilities like doc-in-the-box if they can afford it. Or, they may go without care. But when managed care patients come to us, the plans only pay about 40 cents on the dollar. The plans make it difficult for us to stay in business," she says.
However, there appears to be at least one point of consensus between emergency care and managed care professionals, Kosnik adds. "We think that holding people for observation of chest pain is good use of the ED. At Overlook, all chest pain observations are under this department."
No quarrel from Ellen Gaucher, MPH, MSN, vice president for Quality and Customer Satis faction at Wellmark Inc., an insurance plan in Des Moines, IA.
"Observation for chest pain is important," she affirms. "In the old days, we used to admit them, but observation in the emergency room is a cost-effective way to care for chest pain sufferers. However, I would expect the hospital to follow a protocol of symptoms and risk factors for keeping patients in the emergency room."
Of course, managed care plans can be expected to enforce prior authorization rules. Gaucher adds that most plans monitor the catch rates between observations and diagnoses of cardiac problems.
Reference
1. Williams RM. The cost of visits to emergency departments. N Engl J Med 1996; 334:642-646.
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