The Calculus of Patient Satisfaction
A woman limps into the ED with ankle pain and isolated tenderness over her anterior talofibular ligament. The doctor, who is simultaneously managing several sick patients, smiles and says, “You don’t need an X-ray. I’ll get you out of here in minute.” The nurse then applies a stirrup splint, explains the discharge instructions, and directs her to the exit. The patient thinks, “I just forked over $200 (insurance copayment) yet they are brushing me off without an X-ray.” The next day, the patient is emailed a self-survey request to assess her experience. She categorizes the doctor as “very poor” prompting the medical director to ask the emergency physician “What happened?” Reflecting back, the doctor defensively says, “We got her in and out faster and better than any ED around. No criteria were met for imaging. Plus, she never told me or the nurse about any unmet expectations. And if I ordered a film, she would have lingered at least an hour since a real trauma was arriving by ambulance.” Sound familiar?
The complaint in the case example may have been prevented had the emergency physician or primary nurse asked if the patient had any questions or concerns about the care being rendered before discharge. Eliciting patient concerns would have likely shed light on the expectation of an X-ray and, perhaps, a discussion of the Ottawa Ankle Rules.
There are so many things that can become a satisfaction issue that perfection is improbable. It is certainly plausible that any of the following complaints might be shared on the follow-up phone call:
At Edward Hospital in Naperville, IL, a 75% rate of being awarded the top service score (on a 5-point scale) correlates with the 95th percentile in satisfaction relative to other high-volume, community EDs. Stated differently, despite care being judged as deficient a quarter of the time, an ED can be ranked in the top 5% nationally. (Note that the relationship between top score and satisfaction percentile is sigmoidal and bears an uncanny resemblance to pO2:SpO2 pairings on the normal oxy-hemoglobin dissociation curve.)
Imperfection in patient satisfaction is expected and, in fact, often appropriate. An example is when a non-urgent patient feels “rushed” because an emergent patient requires far more attention from the team. By nature, EDs are “satisfaction-challenged” due to the unpredictable nature of arrival volume/acuity as well as the angst and aggravation that patients experience when faced with an emergency medical condition. This is sometimes unfairly transferred to the ED staff. While some degree of satisfaction failure is not a barrier to being a top performer, when staffing thins and there is only enough time for essential care, satisfaction failure becomes excessive. The difference between a good and a great ED regarding satisfaction reflects persistent efforts to keep the proverbial margin as narrow as possible.
Unlike many other areas of medicine, every ED has a unique struggle. Patients must succumb to the will of providers that they have just met. Emergency physicians that connect effortlessly and garner confidence within minutes are much more likely to watch the next few hours of testing and treatment go by smoothly.
Case Example
A woman limps into the ED with ankle pain and isolated tenderness over her anterior talofibular ligament. The doctor, who is simultaneously managing several sick patients, smiles and says, “You don’t need an X-ray. I’ll get you out of here in minute.” The nurse then applies a stirrup splint, explains the discharge instructions, and directs her to the exit. The patient thinks, “I just forked over $200 (insurance copayment) yet they are brushing me off without an X-ray.” The next day, the patient is emailed a self-survey request to assess her experience. She categorizes the doctor as “very poor” prompting the medical director to ask the emergency physician “What happened?” Reflecting back, the doctor defensively says, “We got her in and out faster and better than any ED around. No criteria were met for imaging. Plus, she never told me or the nurse about any unmet expectations. And if I ordered a film, she would have lingered at least an hour since a real trauma was arriving by ambulance.” Sound familiar?
The complaint in the case example may have been prevented had the emergency physician or primary nurse asked if the patient had any questions or concerns about the care being rendered before discharge. Eliciting patient concerns would have likely shed light on the expectation of an X-ray and, perhaps, a discussion of the Ottawa Ankle Rules.
There are so many things that can become a satisfaction issue that perfection is improbable. It is certainly plausible that any of the following complaints might be shared on the follow-up phone call:
“My boyfriend was not allowed in the exam room.”
“They wouldn’t let me use my cell phone.”
“I waited forever to see a doctor.”
“The doctor was sloppy; he was unshaven, and his shirt wasn’t tucked in.”
“I saw blood stains on the drapes from another case.”
“I asked several times for a drink of water.”
“The orthopedic office doesn’t take my insurance.”
At Edward Hospital in Naperville, IL, a 75% rate of being awarded the top service score (on a 5-point scale) correlates with the 95th percentile in satisfaction relative to other high-volume, community EDs. Stated differently, despite care being judged as deficient a quarter of the time, an ED can be ranked in the top 5% nationally. (Note that the relationship between top score and satisfaction percentile is sigmoidal and bears an uncanny resemblance to pO2:SpO2 pairings on the normal oxy-hemoglobin dissociation curve.)
Imperfection in patient satisfaction is expected and, in fact, often appropriate. An example is when a non-urgent patient feels “rushed” because an emergent patient requires far more attention from the team. By nature, EDs are “satisfaction-challenged” due to the unpredictable nature of arrival volume/acuity as well as the angst and aggravation that patients experience when faced with an emergency medical condition. This is sometimes unfairly transferred to the ED staff. While some degree of satisfaction failure is not a barrier to being a top performer, when staffing thins and there is only enough time for essential care, satisfaction failure becomes excessive. The difference between a good and a great ED regarding satisfaction reflects persistent efforts to keep the proverbial margin as narrow as possible.
Unlike many other areas of medicine, every ED has a unique struggle. Patients must succumb to the will of providers that they have just met. Emergency physicians that connect effortlessly and garner confidence within minutes are much more likely to watch the next few hours of testing and treatment go by smoothly.
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