Simple Tips to Improve Patient Satisfaction

Michael Pulia, MD FAAEM


June 16, 2011

Abstract and Introduction


"Welcome to the emergency department. May I take your order?"
"I'll take the chest pain value work-up."
"An EKG with a side of blood work. Any toppings today?"
"Sure how about aspirin, nitroglycerin and dilaudid. Morphine makes
me itchy."
"Would you like a CXR with that?"
"No, I want to supersize that to a CT scan."
"That will be an extra $2,000; is that okay?"
"Sure, why not!"
"Okay that will be $50 with your co-pay; anything else?"
"Yes, make it snappy!"

Does this conversation sound even vaguely familiar? If so, it should be easy to convince you that the era of McMedicine has come to an ED near you. Although I used this factitious interaction as hyperbole, it does reflect the daily struggles we face in trying to provide excellent patient care while meeting the expectations of patients who are more informed and demanding than ever. A lack of formalized training in patient satisfaction during residency combined with responsibility for factors beyond our control (e.g., facility quality, boarding patients in the ED) makes this task more than frustrating at times. Regardless of your opinion on these new expectations, it is long past the time for lamenting a bygone era of medicine, when interacting with patients in a paternalistic manner was the norm and patient satisfaction was a foreign concept. Like it or not, to thrive in this new reality, we have to start seeing patients as they see themselves: informed health care consumers. Through education and practice, we can develop the skills needed to meet this challenge head-on.

If you are still resisting jumping on the "service with a smile" bandwagon, it might just run you over. Today, there are online reservations for ED visits, publically broadcasted wait times, patient comfort rounds, drive-through vaccination programs, hospital-employed patient advocates and retail clinics trying to meet these new demands. Meanwhile, as the ED is more frequently the gateway into a health care system, it is important to realize that patients' experiences here can influence decisions about future use and referrals. In order to keep up with the competition, administrators are focusing on patient feedback as a measure of quality care, which ultimately results in greater scrutiny on how you provide care, not just your outcomes. Combine this with trends in pay for performance, and both your job security and bottom line could be affected.

Yet it is not all doom and gloom. The patient satisfaction game does offer a bright side. Success in this area has been shown to reduce malpractice exposure, enhance perceptions of your clinical competence, raise levels of patient compliance and improve job satisfaction and morale.[1–10] Thus, instead of focusing on the negative, it is helpful to look to these positive outcomes as motivation for examining some of the simple steps you can use during your next shift to start improving patient satisfaction.

Before outlining specific techniques to improve patient satisfaction, it is important to understand exactly what patients expect when they arrive at the ED. Thankfully, a significant amount of research has already been conducted to define the physician-related determinants of patient satisfaction in EM. An oversimplified summary of these efforts is that our patients want rapid/efficient care from a physician who is empathetic and communicates well.[10–13] Although it seems like such a simple statement, it is in fact deceptive in that it lists subjective components that vary from patient to patient. Still, keeping this statement in mind, we can use some simple strategies to meet the demands of the majority who have reasonable expectations about their ED experience.

The one factor that seems to rise above the rest for ED patients is wait time. They do not want to wait at any time during the experience, which includes time to registration, time to triage, time to room placement, time to treatment by the physician and time to disposition. Of course, most of this wait time is beyond your immediate control. Aside from getting involved in the process of determining how your ED is run (e.g., bedside triage/registration, physician in triage), there is not much you can do change these built-in times. However, when it comes to wait times, it is crucial to understand that perception is not always reality. It might be surprising to learn that patients' perception of wait time can vary significantly from the actual time elapsed.[14] This disconnect provides the opportunity for us to utilize techniques that can alter perceptions of time and bend the satisfaction curve in our favor. Achieving this goal requires two steps: setting expectations and providing explanations.

Each initial interaction with patients should conclude with an estimated timeline of the encounter. Setting expectations by letting patients know the exact steps and timing of a workup for their particular complaint will ultimately reduce uncertainty, mitigate stress and demonstrate respect for the logistics of their lives. This brief interaction changes their perception of wait times, which has a bigger influence on patient satisfaction than actual wait time..[14,15] When utilizing this technique, it is important to remember the business principle of "under promise, over deliver." By setting the estimated time at a mark you can meet or beat 99% of the time, you are more likely to end up with a pleasantly surprised patient who has waited less time than expected.

Meanwhile, the explanation component of this technique is used in those circumstances when the workup is taking longer than you initially promised. From a patient's perspective, the only thing worse than waiting is waiting without receiving any explanation. If you underestimate the time, you must go see the patient, apologize, explain the exact nature of the delay, and then provide an updated encounter timeline. A similar approach can be used during the initial interaction if the triage-to-physician time takes more than one hour (the average time patients feel they should wait regardless of acuity).[16] In most facilities, it is most likely impossible to ensure that each patient is seen in less than one hour; therefore, this may seem like an unreasonable expectation. Nevertheless, the best approach is to understand the expectation and offer a brief apology and explanation when we fail to meet it. Doing so will typically diffuse any anger and frustration that the patient has built up while allowing you to move forward with the encounter.

In addition to wait times, patients seem to place significant value on physician empathy when considering satisfaction. Empathy is a decidedly subjective factor, but it is not exclusively personality driven. A few specific actions could make a significant difference between being perceived as warm and kind or cold and callous. For instance, sitting down during the encounter has been shown to increase the perceived physician bedside time.[17] Undoubtedly, if patients feel that you spend a sufficient amount of time listening to all their concerns, they will perceive you as caring. In the time crunch inherent in EM, anything we can do to enhance the time we spend with the patient (whether real or perceived) is of tremendous value.[18] Furthermore, research on physicians' body language in the clinic setting suggests that a seated position with your torso and legs facing the patient is important for establishing collaborative interaction and demonstrating active listening. Sitting down is especially important in the ED because, as opposed to a traditional office visit where both physician and patient are seated, our patients are typically in the more vulnerable prone position with us standing over them. Therefore, whenever possible, we should try to recreate the framework that people are accustomed to when they interact with a physician to relay a complaint. This not only creates a familiar dynamic, but also lets patients know that we are fully engaged with what they have to tell us.[19] Although perceived empathy is subjective, simple actions like sitting down can influence patient perception and significantly improve your effectiveness in this area.

These simple techniques merely scratch the surface of what you can do to improve your patient satisfaction scores. Each clinical scenario presents unique challenges in terms of patient expectations, so use your best judgment when developing a plan to win patients over. Patient satisfaction will only become more important in the future. Improving our efforts in this area will benefit us and our patients in numerous ways, which should be enough to convince everyone to get on board. By continuing to educate ourselves and practice new methods, we can integrate these skills into our clinical practice and use them as another tool in our arsenal of excellent patient care.


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