By Bradley Chappell, DO, MHA, FACOEP, FACEP
The triple aim of healthcare, as defined by the Institute for Healthcare Improvement, is increased QUALITY, decreased COST, and PATIENT SATISFACTION.¹ If you work in a community setting, there is rarely a shift you work that patient satisfaction does not cross your mind. Many groups financially incentivize you to keep this concept at the forefront of your thought process. Often, the motivation is to avoid the principal’s office (your medical director) as they formulate a response to a patient complaint letter. So what is the importance of patient satisfaction as long as you are providing quality medical care? After all, there is some research that suggests higher patient satisfaction equates to increased mortality.²
There are a few reasons you should care about those survey scores:
1) They are not going away! Whether Press-Ganey, ED-CAHPS, or another tool that you may use for MOC, there will always be some measurement of your service to patients.
2) Consider this an opportunity to externally validate the quality care we all think we are providing. Few physicians show up to work and plan on providing sub-par medical care, but the idiom of “they don’t care how much you know, until they know how much you care” is very applicable to our environment. Perception of care is in fact the reality.
3) Risk Management: Even if there is a poor outcome, if you communicate well and patients trust you are doing your best, the likelihood of litigation is much lower.
“Ok, I get it. Now how can I improve the perception of the quality care I am providing?” I will pick on Press-Ganey since it is the most popular ED tool used. Remember, this is an open book test. There are no surprise questions. The four areas of questioning related to the provider are courtesy, listening, keeping the patient/family informed, and comfort. Overall, teamwork, cleanliness, and privacy are also touched upon. You have the answer key, now address the problem areas at your facility. Here are a few tips:
1) Dress professionally: nice clothes and a white coat are preferred, especially if dealing with a more elderly population. If you wear scrubs, they should be neat (not looking like they were wadded up in the bottom of your locker or the scrub machine for the past week).
2) Touch the patient. We are humans – we like to be touched. Even if you are the physician in triage, shake hands (unless they have a rash or scabies), touch the area of chief complaint, etc. And of course, the visible show of washing hands or foaming is important.
3) Introduce yourself and shake hands with everyone in the room. Who do you think fills out grandma’s survey most of the time? It is often the family member who was uninformed of the reason for a wait because they went to get food or arrived long after your initial encounter with the patient.
4) Sit down when in the room, preferably close to the patient’s head and below their eye level. It makes it seem like you are in the room nearly twice as long as reality, and gives the patient a feeling of being in a power position. Talk to your hospital as this will require a stool in every patient care room.
5) Set patient expectations – and go with the Disney model. You and I know it takes five minutes to run a urine. However, your lab takes 45 minutes. So let the patient know it will be about 90 minutes for the results of the microscopic analysis of their urine (sounds fancy, right). Worst case scenario, you get wrapped up with a critical patient, or lab is running slow, and you deliver results to the patient within 75 minutes, still beating the expected timer. Best case scenario, it gets done as expected and you have the patient’s care completed and them home in less than an hour – “Wow, my doctor was super-fast!” Words like neuroradiologist (aka, the same guy that reads all your other films) and traumatologist (sometimes the PGY2 surgery resident) make it sound worth the four-hour wait for such a specialist to review the imaging.
6) Don’t be sabotaged by a “referring” doctor; be direct: “We have 18 indications for which I can order an MRI in the ED, and Dr. Jones knows that your knee MRI is not one of them. Here is some ibuprofen and crutches, and Dr. Jones can make an appointment for your MRI and directly refer you to an orthopedic surgeon after he gets the results.”
7) Manage up – tell the patient how great the team taking care of them is, and it is likely your team will reciprocate this gesture. Everyone feels more at ease when they feel they are safe and in good hands. And even if it is not your best team, think of something positive to say!
8) Before leaving the room, ask the patient (and family), “What questions do you have?” By phrasing it this way, as opposed to “Do you have any questions?”, it makes it seem like they should have questions; and even if it’s a silly question, it is okay to ask. One of the most frequent causes for (unnecessary) return visits is the lack of clarity at the time of discharge.
9) Update the patient every 60-90 minutes. “Most of your blood work is back and looks good, but we are still waiting for X. Are you feeling less nauseous? Is your belly feeling better? Is there anything you need right now?” Keep the patient informed of why they are waiting; if they know there is a purpose for the delay, they are less likely to be frustrated.
10) Don’t be disheartened by one bad survey. Your scores are highly dependent on the number of surveys during the reporting period, and one bad review can sink your scores for a few months. But that is okay – the point of reviewing the surveys is to learn (and potentially change behavior) for future encounters. If given the opportunity, read each survey and look for items that may seem exaggerated but are legitimate areas you can improve upon.
11) Pay attention to your patients. Being at teaching hospitals, I would often be the 4th or 5th person to ask the story (triage, room nurse, medical student, and resident). I noticed that several people would make comments like, “Don’t you guys talk to each other” (yes, but I want to make sure I have the right story) or “I’m tired of telling everyone the same thing” (by now, you should have a very polished story). So I put a blurb on my business cards simply explaining, “As this is a teaching hospital, you may tell your story to a student, resident, and attending physician – together with the nurse and ancillary staff, we are your care team. If at any point you do not feel we are exceeding your expectations, please notify me immediately so I can address your concerns.”
12) Give the patient or responsible party in the room your business card either during introductions or as you are leaving the room (“Here is my card; please let me know if you need anything”). I put my cell on it and over the years have only gotten 2 calls – both of whom I was happy to help and glad they called. Obviously there may be some patients you selectively do NOT hand those cards to, but you may keep a stash of your least favorite partner’s cards to hand to your special patients!
13) Call the patient the next day to see how they are feeling, if their pain is better, if they have any questions about their discharge instructions, etc. This is an excellent opportunity to clarify anything that was unclear at the point of discharge as well as have the patient return if there is something concerning about their outpatient progress.
14) This is a team effort, so you will need institutional buy-in. One hospital I worked at used whiteboards in the rooms. The doctor and nurse would write their names on the board so the patient was clear who was caring for them, then there were areas of the board to inform the patient which labs were ordered (i.e. we need a urine from you), and most importantly, what the goal of the visit was (rule out appendicitis, stop vomiting, see the orthopedist, etc.). There is nothing worse than going in to discharge the patient, and they bring up a new issue. “What about my chest pain?” or “Why am I still dizzy?” Don’t assume they will bring it up in their chief complaint/HPI and you may miss something on your thorough 14 point ROS.
These are some things you may find helpful, already do, or possibly never thought of. I’m sure many of you have some tips and tricks you have learned over the years, so please post your comments so we can all benefit from your wisdom!
Sincerely,
Bradley Chappell, DO, MHA, FACOEP, FACEP
1. Institute for Healthcare Improvement Triple Aim Initiative, http://www.ihi.org/engage/initiatives/tripleaim/pages/default.aspx , referenced 8/30/16.
2. The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality, JAMA 2012. Use caution when quoting this study as it was an observational study which makes it difficult to infer a causal relationship. Per their analysis, satisfied patients tended to be higher utilizers of care, but this does not imply it was value-added care. They also had fewer ED visits, a higher number of inpatient days, and higher overall healthcare costs as well as prescription drug expenditures. The biggest concern raised by the authors was whether providers modify their behavior based on patient satisfaction scores, potentially leading to “unintended adverse outcomes”.
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