Improving the Patient Experience


Your CEO has told you she needs to see your department’s patient satisfaction scores improve or she’ll be looking for a new chairman. What do you do next?

CEOs of hospitals know that patient experience scores are basically the hospital’s reputation, and that ED scores correlate with inpatient scores, but this feeling may not trickle down to your providers and staff. The hospital has a real financial incentive to have great patient sat scores. Even before CMS started outcomes-based reimbursement, studies support that good patient experience may increase patient volume, and perhaps more importantly, may prevent ED volumes from declining.

With many patients seeing higher co-pays and higher deductibles, they’re expecting more from the ED or else they may take their lower acuity complaints to urgent cares. Current CMS hospital star scores and Value Based Purchasing programs have a significant patient experience component and since most patients are admitted through the ED, the ED can help or hinder the scores the hospital achieves. The ED is the front door to the hospital and needs to be part of the solution, not a problem for our hospital partners.


In addition to financial reasons, patients follow the physician’s care plan better when they view their physician favorably, and liability is greatly reduced when patients rate their care higher. ED CAHPS, sometimes referred to EDPECs (for Patient’s Experiences with Care) is in a trial period and will likely be tied to reimbursement in the next few years. What’s especially interesting about ED CAHPS is that at go-live, all EDs around the country will have the same survey questions, will be compared against each other, and be publicly reported.

Another big change that ED CAHPS will bring to the table is that it will survey both admitted and discharged patients. Currently, most ED patient engagement surveys only cover discharged patients. As many hospitals know, you don’t start improving the patient experience at the last minute. That just doesn’t work. Building an excellent patient experience culture and improving overall scores takes time.

As medical directors, we need our team to understand why patient experience is important and for them to be individually engaged in the process. As managers, we need to provide feedback and coaching to our staff. We also need to make sure our EDs are operating efficiently.



A fully engaged team, with a goal of improving all aspects of the patient experience, is the key to succeeding here. Culture doesn’t change overnight but needs to improve over time to get sustained results for the good of your patients and your team morale. Having the key leaders in your department on board is the first step. Then, bringing your team together, asking for their input, and allowing them to shape new trials of process improvement (even if they fail) improves staff morale, reduces turnover, and vastly improves your working environment. Making sure your providers “manage up” your nurses and techs at the bedside improves teamwork, gives patients confidence in their treatment plan, and improves care coordination, which is a common survey question.

When your staff is happy, your patients reap the benefits. Emphasizing the patient in all your efforts goes a long way to bringing the team together for a common goal. Implementing employee surveys can drive engagement and spark your team into improving the patient experience. Managers are much more likely to get long-term success with an engaged culture than from one in which providers are simply doing what their manager tells them to do. Some staff may not respond well to a campaign focused solely on patient satisfaction. However, if you frame the discussion around the patient experience, which includes flow, patient safety, and staff satisfaction, buy in and staff engagement will likely increase.

Again, a happy, engaged team makes for a great environment for patients. According to Press Ganey, staff showing that they care is essential to high “likelihood to recommend” (LTR) scores. While it’s hard to change that culture if it’s buried beneath staff shortages, getting your hospital CEO to publicly make the patient experience a high priority for the organization can help rally your department toward the goal and make your job easier.



In addition to working on your culture by engaging with your team, the high-performing EDs of the nation get their wait time and length of stay down as well. This is especially key if your culture is not there yet, according to 2017 Press Ganey data. If your staff culture is a work in progress, your physicians can really help by focusing on being courteous and providing initial care under 30 minutes.

Our CEOs want us to fix many things despite the negative impact on the ED by boarders and staff shortages throughout the hospital. As we have seen over the years, the ED population is aging and more complex, and ED LOS averages have increased across the nation. This is a challenge and will take time for real success, but there are steps to get there.

Some metrics can be improved quickly, others cannot. Survey data shows that reduced door-to-provider times and length of stay can improve all your scores, because they greatly impact perception of the overall experience. Flow really matters. For every hour a patient stays in the ER over 2 hours, there is approximately a 5% drop in likelihood to recommend (LTR) top box score for that visit.

While triage bypass or direct to bed should be the goal, I realize that almost all EDs end up with patients in a waiting room. Since “in-process” waits are better perceived than pre-process waits, work on creating an up-front process that allows patients to easily know where they are in the queue and set a goal of beginning triage protocols, taking vital signs, and using scripts stating your care is “in-process.” That way, patients know staff are fully aware of their needs and are attending to them as quickly as possible.

Getting the patients work up “in-process” by getting tests started up front reduces LOS, which ultimately frees up bed space downstream. Also, consider using lean principles to take out any non-value added processes that are not important to the patient.


Use of a mnemonic like Studer’s AIDET or others can help your team communicate in a professional manner. Providing best practice scripting for service recovery, such as with Cleveland Clinic’s H.E.A.R.T technique (Hear the story, Emphasize, Apologize, Respond to concerns, Thank), can help your team quickly interact more positively with patients.

I’ve looked at thousands and thousands of patient surveys and comments, and there’s clearly themes that emerge. Patients expect high quality but have a hard time judging it. While we occasionally have a “miss,” it’s not the most common complaint or comment that I see. Patients become frustrated when they sense inefficiency or they don’t know what they’re waiting for. Overestimating the wait time for tests can go a long way to exceeding the patient’s expectations. Wait times for common studies can be put on signs in rooms, on a poster in the waiting room or put on a pamphlet that can be handed to patients at arrival.

Waiting room introductory videos can help explain the process as well. Patients pick up on rude or curt behavior from providers or staff. Sometimes it’s the provider mirroring the patient’s behavior but more often, it’s a provider who’s busy or has multiple sick patients and just isn’t appropriately focused on the patient at hand.

Patients feel rushed or that the providers don’t care when they notice the provider checking their watch. We know we only have a few minutes for the patient but sitting down and taking the extra few seconds to explain the anticipated course and ask if there’s any questions goes a long way. Hitting the trifecta of patient care involves high quality, fast and efficient care, and friendly but efficient communication.


The easiest way to improve patient satisfaction might be to take a lesson from corporate giants in customer service. When you call for help, the good ones end the phone call by some sort of question that
solicits feedback and confirms the customer is pleased with the outcome. While most physicians have a sense of their patients’ demeanors, it’s best not to assume and certainly wouldn’t hurt to implement a protocol of inquiry at the end of any treatment.

Showing that you care is as simple as asking, “Is there anything else you need? Have I answered all your questions?” before rushing to your next case and goes a long way to increasing satisfaction. If you’re looking for a “quick fix,” calling discharged patients may be the closest thing to it. It has been shown to significantly improve the patient’s overall rating of their visit. Many are shocked to receive this service, so it is a worthwhile investment not just for low performers among your staff, but also to improve overall scores for the whole department.

This is especially true if the overall length of stay is high. Receiving a follow-up call from an ER doctor can greatly improve the overall impression of the ER and hospital and reduce the risk of a bad outcome, which is why it is becoming a standard in the highest performing ERs.


Managing low performers and highlighting great patient feedback is also necessary for any director. Having goals for individuals and clear expectations for their behavior with patients is the start. Likewise, having relevant data to share with your team is essential to drive performance. If you don’t have data, you may need to find a way to gather it through an outside vendor. If you only have hospital survey data, this can still be used to identify high and low performers, but often does not have enough surveys per month to provide significant and timely feedback.

Quarterly data or past 6 months data may be helpful in this case. Previously, I worked in an environment where quarterly 1:1 meetings with providers to review metrics were required. Although I don’t think anyone enjoyed them, they were pretty benign and led to tremendous improvements in all aspects of ED performance. Regardless of your methods, sharing positive comments in public, sharing negative feedback with individuals in private, and sharing provider performance (if enough data is available to be relevant) at site meetings, will drive your low performers to improve. Observations and evaluations are necessary to drive performance, as your team needs accountability when your job is on the line.

All management of this should be paired with coaching, which is a critical aspect of being a medical director and/or chair. Coaching should include the tools to improve as listed above and the clear message that patient satisfaction is controllable with effort and focus.


Your healthcare team went into medicine not to perform well on surveys but to provide excellent care to their patients. So, unfortunately, the reasons why patient experience scores are so important to the CEO, such as reimbursement and reputation of the hospital, don’t motivate your team well. When in a position to change your culture, avoid focusing on scores because they are not a great motivator.

This may work for those you directly manage but doesn’t work well for those you don’t, such as nurses and techs, if you are a contract group. A director should understand the survey scores and find a way to motivate their team in a way that allows for team engagement towards the goal. Focusing on the patient and the patient’s view of their experience is a great way to rally your team towards your ER’s goal of improving care.

Reasonable wait times, friendly staff, and exceptional care are all expectations of our patients. If you create the vision in your staff, keep the focus on the patients, and work with your underperformers, your scores will improve so that your CEO can be proud of your team’s efforts.


EXECUTIVE EDITOR Dr. Silverman is Chair of Emergency Medicine at VHC Health. He also taught a leadership development course for over a decade. Dr. Silverman’s practical wisdom is available in an easy-to-use reference guide, available on Amazon. Follow on Twitter @drmikesilverman

Dr. Schnabel is a practicing emergency physician and the director of patient experience for Alteon Health.


  1. Patient satisfaction is a laudable idea when it doesn’t interfere with sound medical decision-making. All too often patient perception is diametrically opposed to what has been proven to provide good outcomes. We will likely come to a consensus on all of this at some point when all actions are payer driven, which of course means that if you are not a payer then no one will likely care.

  2. Glad to help any ED chais/medical director with his/her PX struggles. I run a two-ED system that has acheived top-decile satisfaction for years. Our success is multifactorial and truly a team effort. We are fortunate to have the support of senior admistrators who understand the importance of PX (loyalty, ED-CAHPS prep, promotes staff satisfaction) and give us the resources we need. Feel free to contact me at [email protected].

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