I keep hearing that the federal government is getting into the Patient Satisfaction business through something called ED-CAHPS. Is this like Press Ganey? I just want to focus on clinical excellence and patient safety – satisfaction seems to be all about fluffing pillows. Is ED CAHPS real and if so, how can we prepare?
If you didn’t like Press Ganey, you’re not going like ED-CAHPS, but the Fed’s version of patient sat surveys is here to stay, and will soon impact reimbursement. So get your head out of the sand.
The Emergency Department Consumer Assessment of Healthcare Providers and Systems (ED-CAHPS) is the next government-mandated survey designed to improve the nation’s quality of healthcare . . . and it’s coming soon to your ED. This could occur as early as the second quarter of 2014 – that’s now. Although it will probably take longer to start, reimbursement is expected to be tied to ED-CAHPS by 2015. Therefore, if you’ve buried your head in the sand in regards to patient sat, or just feel that patient sat scores don’t matter, this will force you to address the issue head on.
Why Should We Care about Patient Satisfaction?
On one hand, we’ve heard that satisfied patients are less likely to file a suit in the event of a bad outcome and more likely to be compliant with discharge instructions. On the other hand, in a 2012 study published in the Archives of Internal Medicine, researchers at UC-Davis found that the most satisfied patients had a 26% higher mortality rate, a 9% higher cost, spent more on medications, and were more likely to be admitted as inpatients. The methodology of this study has been questioned, but it demonstrates the complexity of the patient sat issue. If focusing on patient satisfaction actually undermines care, is it even in line with the Hippocratic Oath? In the end, however, we’ve moved past the realm of philosophical debate and now have to deal with basic compliance. The government has changed the game, and whether we like it or not, we’re taking part.
CAHPS: The Basics
The CAHPS initiative has been used in the in-patient setting for several years to evaluate the perceptions of consumers and patients on multiple aspects of healthcare. Survey instruments have been standardized and this allows for comparison of results over time and across multiple sites. CMS’s goal in developing the ED version is to better understand the ED experiences from the patient’s perspective, allow for objective comparisons of care that patients receive, and improve the quality of ED visits across the country. In keeping with most ED patient sat surveys, the survey will focus on discharged patients. There shouldn’t be any surprises in the survey. Questions should continue to hit on the big topics that our administrators like to evaluate us on such as overall rating of the ED, willingness to recommend and overall ED visit. Additionally, expect questions on communication (specifically associated with providers, medications, and explanations of tests), pain management, arrival and discharge process and information, wait time, and nursing and physician care. A new question (for most of us) will ask about interpreter services. Unlike some of the current rating scales with a 1-5 score, expect behavior based scores such as “never, sometimes, usually, and always,” where we will be compared based on our percentage of “top box,” always, responses.
You don’t have to be a rocket scientist to improve patient satisfaction, but you do have to accept the fact that patient sat is an indicator of performance and recognize the growing financial implications to the hospital. Because of HCAHPS, the in-patient version for patient sat, savvy CEOs already know that a better ED experience leads to a higher HCAHPS score. But what specifically improves the ED experience? We know that shorter times from door to provider and overall length of stay improve patient satisfaction. Research also shows a clear relationship between providing good and adequate pain relief and higher patient satisfaction. Beyond that, good manners seem to go a long way.
Simple Improvements: The Patient Encounter
There are some simple – and free – measures that can improve the patient experience and can be implemented immediately.
- Start by knocking on the door and getting permission to enter. After all, nothing will start the visit off worse than walking in on someone who is half naked and trying to figure out how the gown works.
- Once in the room, introduce yourself with your title to everyone in the room and find out exactly who the visitors are and if the patient is agreeable to having visitors in the room during the history and physical.
- We have a tendency to interrupt patients early in the history so try to sit back and let them talk for a bit. Paraphrase and repeat back the important part of the history so you can be sure you’re addressing the key issues and so that the patient knows you’re listening. Be sure to give everyone in the room a chance to speak.
- After the H and P, take a minute to lay out the plan for the patient with the expected time estimates. Think how happy you are when you go to a restaurant and the hostess tells you it’s a 45 minute wait but you get a table in 25 minutes. It’s better to “under-promise and then over-deliver.” I’ll tell patients that labs will be back in an hour, even though we consistently get results in 45 minutes. That lets me either surprise them that results were faster than expected or it covers me if I get tied up with another patient. I usually will tell the patient how many hours I expect their entire ED visit to take as well.
- Before I leave the room, I hand the patient a business card. This clarifies my name and serves as an additional reminder to the patient that I’m their individual doctor and not just the “ER doc.”
- After the initial visit, it’s important to get back to the patient every 30-60 minutes to either check on the impact of a treatment (pain controlled, vomiting better, breathing better) or to give results and updates of next steps. Phrases like “Let me inform you what’s going on….” and “Your evaluation shows….” can go along way towards alleviating anxiety.
- Because pain control is so important to the patient, excluding the small percentage of patients who are drug seekers, be sure to ask the patient each time if they’re comfortable or need anything else. To steal a line from one of my favorite lecturers, I make sure to tell the patient that I have plenty of pain meds for them, and we won’t run out.
- At the end of the visit, explain the diagnosis, treatment and follow up. Educate the patient and family if possible and then be sure that all of their concerns are addressed.
- As a final step, I ask, “Is there anything else I can do for you?” This is a scary phrase to mutter in the middle of a busy shift with a rack full of charts waiting for you. But I’ve consistently found that it’s very rare for patients to say anything but thank you. Occasionally, I get the reminder for the work note but it’s rare that I’m asked to evaluate a new problem.
- Finally, if you’re really serious about improving patient satisfaction, you should do a follow up phone call with your patients within 1-2 days. I was not a believer in this concept until we tried it at an urban ED that I worked in and I watched our patient sat climb from very low in our control group to above the 90th percentile for patients we called. I get the best phone number from the patient during their visit and tell them when I’m going to call. Patients are always grateful; I can answer any questions, and remind them to follow up (on occasional I’ve even told them to return to the ED). Calls take on average about a minute each. There’s even a published study showing that emailing patients is at least as effective as a follow up phone call.
Field test results for ED-CAHPS are expected any day. If approved, it won’t be long until the survey is initiated and you can expect ED reimbursement to be tied to ED CAHPS performance in the near future. The ace in the hole for a director is that this is an open book test. The questions will be announced and you can work with your medical and nursing teams to focus on the key aspects of the ED visit. There shouldn’t be any surprises. It may mean that more time is spent on med rec or explaining side effects of new prescriptions, but this is actually good for the patient. As with any core measure, preparation and coaching go a long way towards department success. Departments that succeed in this will be those that completely buy in to the hospital’s agenda that patient satisfaction matters and start working to make improvements sooner rather than later. While there is a role for improving operational efficiency, there are also bedside phrases and key elements that physicians can easily learn and incorporate into their daily practice.
Michael Silverman, MD, is a partner at Emergency Medicine Associates and is chairman of emergency medicine at the Virginia Hospital Center.
Automated patient callback systems can help satisfy patient sat goals
By Tom Scaletta, MD
In most EDs the concept of post-discharge patient follow-up is either non- existent or just in its infancy. Yet with over 100 million ED discharges each year, this is clearly a critical juncture with patients and an opportunity to improve the patient experience.
Inviting patients to speak up about any medical setbacks or service concerns is a key step in improving care. Fortunately, this does not need to entail an entirely labor-intensive outreach effort. Cutting edge technology specifically designed for this purpose exists, technology which will also help your ED meet federal goals for improving quality, improving the patient experience and controlling costs.
Using Call-Backs to Improved Health Care Quality
Even when applying evidence-based rules to test ordering in emergency medicine, there will always be near misses. This is because an ED visit is often an early snapshot of an evolving situation. Examples include appendicitis and pulmonary embolism masquerading as gastroenteritis and bronchitis, respectively. Accessing the patient at another point in the care continuum—for instance, on the next day using technology to solicit a response to the question, “Are you better, same or worse?”—can make all the difference both clinically and financially. By circumventing one such missed diagnosis just once every other year, hospitals can reap the benefits of a call-back system.
Another important factor in achieving positive patient outcomes is aftercare compliance. Patients who cannot get a specialist appointment, afford a medication, or understand discharge instructions typically do not fare well. Thus, relaying such obstacles to ED case managers so that issues can be addressed during an aftercare phone call can improve recovery.
Using Call-Backs to Enhance the Patient Experience
There are two primary ways patient re-contact can boost patient satisfaction. First, the very act of checking in on a patient is an act of kindness and appreciated, especially when it ties to real action should a wellbeing issue be identified.
Second, when statistically-valid, provider-specific metrics are reported each month, staff are motivated to treat the patient with more attention and demonstrate more empathy—which in turn produces superior results.
Dr. Tom Scaletta is the founder of Smart-ER, an electronic patient call-back system.
What a sad day coming. Every pit Doc knows patient satisfaction is not a measure of good and more importantly, appropriate care period. Again, it’s just all about the money.
Stop with the cheer-leading. Stop saying that these surveys are an indicator or performance, when in fact they indicate nothing more than a perception of reality. Stop saying that pt-sat is here to stay and we need to get used to it. That is like telling a patient that “you have hemorrhoids, just get used to it.”
Why have our professional organizations and physicians in leadership positions sold us out? Satisfaction is not equivalent to quality. After working so hard, for so many years to make our specialty respected in the medical community, we have been whored out to the business interests. Interests that are out to grab as much money and control as possible. We are not a service industry. We are a profession of highly skilled and experienced individuals. My compliance is to that of medical standards of care, not some arbitrary survey based on a variably variable variable. You might as well declare that cucumbers should emit sunbeams and we need to get on board with this. I am not a lemming.
Now, I do not go into a shift thinking about how I can piss patients off or treat them poorly. However, placing the physician in a position of cowering before the threat of a poor satisfaction score is belittling the relationship between a doctor and patient. If the patient is always right, then just give them a menu and let them treat themselves. If however the patient presents asking for an expert medical opinion, the doctor should not have to be afraid to give it, even if the patient does not like the answer.
Last Saturday, every patient I saw was either drunk, in custody, high or psychotic. So don’t tell me that my experience is the same as someone in a suburban area. I was cursed out no less than 5 times and I am quite sure that several of the patients were not exactly satisfied that my orders did not include 2 pounds of mophine to go.
In all fairness, many of the recommendations are quite reasonable and encourage good communication between the doctor and patient. However, setting the patient up for the expectation that I am going to go back into the room every thirty minutes to update them is ridiculous if you plan to see more than 2 patients an hour. Somewhere in there hoping to keep up with the charting, physician computer order entry, incoming ambulances, procedures and spending time comforting the family of a newly deceased person.
How about this? Why don’t we start with the premise that the vast majority of us do our dead level best. How about assuming that? You don’t have to measure anything. It is just a given. For those of you who feel the need to gather metrics, why don’t you do something with all the data that has been collected before demanding more. For those who think we need to start somewhere, I agree. However, if I am going to drive from New York to San Fran, I am not going to start be flying to India.
I agree with D Bryant’s comment. The ED isn’t Burger King, and sometimes the patient can’t and shouldn’t “have it their way.” Last month out of the couple hundred people I saw, 3 returned a survey. I got a score of 53%. From the written comments, it appears that I angered some people that didn’t get their dilaudid fix. So despite the hundreds of patients that I saw and likely provided care they would likely rate as good, I get in trouble because I didn’t feed the bears. My family and I didn’t sacrifice all that we did during med school and residency just to be a waiter.
Below are the AAEM and ACEP position statements on satisfactions surveys. Our professional organizations are representing us well on the subject.
The driving force behind value-based medicine is public expectation — i.e., consumerism. Our specialty societies can help assure that measures of quality, satisfaction, and efficiency are valid and used appropriately.
D Bryant for President!!!! Awesome commentary on this cancer encroaching upon our practice of Medicine.