Low patient satisfaction scores: the five stages of response.

Imagine you are a medical director and your hospital administrator meets with you to go over the latest emergency department patient satisfaction scores. If your scores are like those at many hospitals, your initial reaction won't be to jump for joy, but rather to either jump or throw someone else--your administrator, perhaps--out the window.

If you are like the majority of your colleagues, your reaction to less-than-desirable scores will be fairly predictable. Coincidentally, this reaction often mirrors the five stages of grief identified by the notable psychiatrist Elisabeth Kubler-Ross (1):

1. Denial

2. Anger

3. Depression

4. Bargaining

5. Acceptance

The first reaction is typically denial. "Those scores can't be correct." The search for excuses begins. Suburban hospitals argue that their patients are of high socio-economic class and very demanding.

Conversely, inner city hospitals claim that low scores result from poor, uneducated patients who do not appreciate the service that is rendered. Invariably, the methodology is questioned.

Other hospitals in the database are not viewed as comparable because they have higher or lower annual visits, are in a different geographic area, or have a demographically different catchment area. The sampling size and response rate will be criticized as too small.

Anger and resentment emerge. "These are patients, not customers. Our mission is to deliver quality care. If patients can't or don't recognize that, then that's their problem."

After anger comes depression related to feelings of failure. Physicians are the classic overachievers. Anything average or less is unacceptable to our psyche.

The next phase involves bargaining with administration over the survey process. You ask for a larger sample size. The 50 to 100 patients typically surveyed per quarter simply are not enough to be "statistically significant." You request adding admitted patients to the mix.

Many survey companies solicit responses only from discharged emergency department patients. Since 20 percent of emergency department patients are admitted to the hospital, it seems logical that excluding them would bias the scores. You ask for a different methodology.

Telephone surveys typically have high response rates, but with a small sample size. Conversely, mail-in surveys have larger sample sizes but with low response rates. Whatever your hospital is using, you are convinced the other is better.

In the end, all of these machinations do little to change the outcome. The scores don't change significantly. The hospital is not about to abandon patient satisfaction surveys. And you don't feel any better about going to work. So how do you get to "acceptance" and what do you do about the scores?

Feeling better or worse

First, realize that patient satisfaction scores are about service delivery and have little to do with the quality of care. Patients have difficulty assessing whether their care was good or bad. They only know that they get better or worse--outcomes that may be unrelated to the quality of care delivered.

I know of patients who received outstanding care yet died from their illness. In that tragic situation, how can the family appreciate the quality of care?

[ILLUSTRATION OMITTED]

When you take your car in for service, do you have any idea of the quality of work performed? I used to take my car to a shop until I read in the newspaper that the owner was arrested for fraud. Allegedly, customers were billed for services that were not actually performed.

Prior to that time, I had been perfectly satisfied with the service. The work was completed on time. The staff was courteous and polite. The mechanic didn't leave grease marks all over my steering wheel. My car continued to run well.

The point is that few of us can judge quality outside our own field. However, we all can judge service. We all have certain expectations of what service we expect to receive. When that service falls short of our expectations, we are dissatisfied. Patients do the same thing to us. They can't judge quality, but they can judge service.

Second, good service delivery is about process efficiency. The components of the system must be synchronized and the process must be efficient.

Southwest Airlines has one of the best on-time records in the industry. Ground crews routinely turn around (clean, restock, and refuel) a 737 in 30 minutes. In a hospital, it can take longer than that to notify housekeeping of a dirty bed. By the time the bed is actually cleaned, hours have passed.

In most emergency departments, walk-in patients are evaluated by a triage nurse and then go through a registration process before being taken to a treatment bed. Patients can experience waits during either triage or registration. It is not uncommon for this process to take 45 minutes, even when beds are available and the staff is not busy. I have often wondered what goes through patients' minds when 45 minutes have elapsed and they are escorted into a relatively empty and quiet department.

Too often, hospitals focus customer service initiatives on "being nice." They hire greeters for the waiting room. Training sessions emphasize smiling, making eye contact, being aware of body language and addressing patients formally.

Although these factors are important, they are not where the money is. For emergency departments, it is all about getting patients in and out.

I interviewed a patient who had returned a survey with abysmal scores in every category. When I asked him about his emergency department experience, he said that everyone was very nice but the "whole thing just took too darn long."

When I looked at his chart, I found that he was right. He was in the ED for five hours for a finger injury that should have taken 60 minutes from door to discharge.

I am aware of a number of hospitals that have implemented customer service programs without deriving any significant improvement in their patient satisfaction scores. However, I also know of hospitals that have reduced patient throughput times, causing their patient satisfaction scores to markedly increase, without customer service training.

Process improvement

Service is a process, and a hospital is a collection of complex processes with multiple points of interaction between the patient and health care workers. Unfortunately, many emergency departments do not deliver very good service at many steps in the process.

Patients wait for hours just to be seen by a physician. They spend entire days, and sometimes nights, in the emergency department, waiting for tests to be completed. They often do not know why they are waiting, much less if they will be discharged or admitted.

Patient satisfaction surveys are not an exact science. However, within a margin of error, the results of a survey performed by a reputable company2 are generally reflective of the community's perception of your emergency department. A p value <0.05 is not required. In other words, the scores are what they are.

Like it or not, we work in a service industry. Consumers, including our patients, have come to expect a certain level of service in all areas. If your patient satisfaction scores are low, you have work to do.

Determine what your patients want. If you are not sure what your patients want, ask them. You won't have to talk to very many of them to get a sense of their priorities. Relying solely on the survey questions can be misleading.

For instance, one of the questions in the survey developed by Press Ganey Associates, Inc., is, "How satisfied were you with the amount of time the physician spent with you?"

On the surface, one would assume that the solution to a low score would be to have the doctors spend more time at the bedside. Unfortunately, this strategy is flawed. In the example cited earlier, the physician probably spent 10 to 15 minutes of the five-hour visit at the bedside. If the physician doubled the amount of time at the bedside, would the patient have been significantly happier?

Senior management support is critical for any significant process change. Without it, any major process change is likely to fail. Open lines of communication to administration are essential to ensure the cooperation of other departments and access to the resources necessary for success.

When improving patient flow, it is important to analyze the problem before trying to solve it. Make a flow chart of an existing process and then decide what the ideal process should look like from the patient's perspective. When re-engineering, eliminate unnecessary steps and, where possible, run processes in parallel instead of sequentially. Improving patient flow is a win-win for everyone.

Joseph R. Twanmoh, MD, FACEP, is an assistant professor of surgery in the division of emergency medicine at University of Maryland School of Medicine in Baltimore, Md., and attending physician in the emergency department at St. Joseph Medical Center, Towson, Md. He can be reached at 410-328-8025 or [e-mail]

[ILLUSTRATION OMITTED]

References

1. Kubler-Ross E. On Death and Dying. New York: Macmillian, 1969.

2. White B. "Measuring patient satisfaction: how to do it and why to bother." Leawood, Kansas; American Academy of Family Physicians, 1999. Available at www.aafp.org/fpm/990100fm/40.html. Accessed on March 8, 2006.

By Joseph R. Twanmoh, MD, FACEP