Improving patient satisfaction begins in the emergency department

Studies show that no matter how positive the patient experience is in the hospital, no matter how much they like their nurses, hospitalists or other providers, if patients have a negative experience in the emergency department (ED), it will affect all aspects of patient satisfaction.

According to the American College of Emergency Physicians, more than 80 percent of unscheduled admissions come from the ED. That's concerning news to those of us working in and for hospitals. Often patients admitted through the ED score the hospital much lower on surveys in all domains versus those electively admitted to the hospital.

Those basic facts are why true patient satisfaction begins in the ED, but it can't end there. For optimal outcomes, patient satisfaction measures need to encompass the entire continuum of care. Especially when patients are handed off to other floors or departments where a good experience can go bad, and vice versa.

Providing good communication such as sitting at the bedside, using AIDET or iCARE communication tools, daily updates with the patient and the family on the diagnoses and treatments, and answering all of their questions and concerns is essential for an optimal patient experience. Additionally, hospitals must look at three core areas to improve patient satisfaction system-wide:
- Initial experience in the ED
- Transitions of care
- How the entire hospital staff communicates and engages with patients

Starting at the Beginning: What happens in the ED
That first moment a patient enters the ED can be critical for establishing a positive patient experience. Recognizing this fact means we need to ensure that the first person the patient meets is pleasant and helpful and that the surroundings are clean and inviting. We need to let each patient know up front what to expect. We can do so by providing a checklist at admission of what the patient can expect or at least the basic information about the patient's likely ED journey.

Additional steps can and perhaps should include the following:
• Developing a system to triage patients and to expedite care for less acute patients. Our hospitals use a system called Rapid Medical Evaluation (RME)® to keep care flowing. Patients deemed unstable or in need of admission and those who will require a more extensive workup are quickly moved to the main ED, while those waiting for results, consults and treatments occupy medical exam chairs near triage (creating an internal waiting room of sorts).
• Communicating clearly and often with patients in the ED is an important step in improving satisfaction. Use whiteboards or care cards that can explain to patients what will happen next and when. If there are delays, don't leave the patient sitting. Instead, explain and provide updates as needed.

Optimize Hand-off and Transitions
When a decision is made to admit, be sure to explain why, and what the patient can expect will happen. A physician can note, for example, "Because of your condition, we feel it is necessary to admit you to the hospital. I called Dr. Smith, who will be your admitting physician, and she will be here in 15 to 30 minutes to meet with you and your family and answer any questions."
At this point, it's important for the ED physician to introduce the hospital medicine provider to the patient. This introduction should include a description of the patient's condition so that he or she sees that a smooth transition is taking place.

Those of us who work daily in the ED sometimes forget that there are a lot of confusing and often frightening activities taking place. That's why it's important to talk about your team and their exceptional levels of skill. The ED physician might say, "I'll be calling Dr. Smith to admit you to the hospital, and you are fortunate that she'll be your physician. She is a great clinician and extremely kind toward her patients."

When Dr. Smith arrives, she can respond, "Dr. Jones explained your diagnosis of pneumonia and asked me to admit you. I've worked with her for many years, and she is one of our top clinicians. We have already talked about your case, but I still need to repeat some of the questions Dr. Jones asked you and examine you to confirm the diagnosis. Then, we will discuss your treatment plan...."

Engaging Leadership
One way to improve patient satisfaction is to incorporate hospital leadership into patient rounding. Rounding teams can include heads of the ED, hospital medicine, the nursing director, and even administrators. This type of rounding makes patients feel as if the entire hospital is working together. It's also an excellent way to identify problems and concerns and to implement service recovery programs. You can explain that the hospital has senior staff on rounds to ensure that each patient gets excellent care and to help the staff recognize what we can do better.

If the patient thought the ED was messy or that a staff person was brisk, then having leadership there to speak with the patient, and acknowledge that steps will be taken, shows an exceptional commitment to patient-centered care.

Of course, hospital leaders are busy, but this step has been shown at several of our hospitals to improve patient satisfaction significantly. Therefore, it is worth taking the time to implement this strategy into administrators' daily schedules. This activity also creates a strong sense of teamwork within the hospital and thus can lead to more collaborative care.

Steps to Take after Discharge
Even after patients are discharged, the hospital still can improve patient satisfaction scores by putting an emphasis on call-backs. Within 48 hours of discharge, we have advanced providers and physicians contact patients to inquire about how those patients are doing and if they are adhering to their physicians' plans of care. Call-backs from the provider can improve patient satisfaction scores significantly.

It's Time to Explore New Options
If your hospital has patient satisfaction scores that are lower than expected, it is likely that you can trace some of those scores to patients' experience in the ED. If so, those scores give you a chance to discuss with ED physicians, nurses and other staff the many steps they might recommend to improve those scores. Such conversations give you an opportunity to connect with physicians and other staff as partners to engage them in the effort and discuss research you've encountered about successful programs in literature or at industry conferences.

If you start with the basics of improving communication with patients and then move on to more advanced steps, such as including administrators rounding on patients and staff, then ED and hospitalist physicians along with nursing staff will recognize and appreciate the effort. Measure and report on your progress and commit to exploring new ideas. The payoff is likely to be worth the effort and will include higher patient satisfaction scores, a more pleasant hospital environment, and a more engaged, effective and integrated hospital team.

About the Author:
Jeffrey Frank, MD Jeffrey Frank, MD, MBA is the Director of Quality and Performance for Emeryville, Calif-based CEP America. In his position he helps create and implement quality programs for more than 250 practice sites nationwide. More information is at

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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