Patient Experience: Beyond Patient Sat

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altDelivering a top quality patient experience is “a mountain without a top.”
Is it time for your EM group to take the first step up?

Delivering a top quality patient experience is “a mountain without a top.”
Is it time for your EM group to take the first step up?


No binary (‘yes’ or ‘no’) patient service satisfaction question is of greater importance to the ED and hospital than “Will you return to and/or recommend our hospital?” In this era of ever-expanding access with choices like extended hours primary care, urgent care centers and freestanding EDs, customer retention is what will increasingly be the factor that separates the winners from the losers.  Customer retention, in turn, is determined primarily by what is being referred to as the “patient experience.”  The Beryl Institute, in an article in the September/October 2011 issue of Becker’s Hospital Review, defines patient experience as “The sum of all interactions, shaped by an organization’s culture, that influence patient perceptions across the continuum of care.” The article goes on to say that “Patients no longer view great (clinical) outcomes as a key differentiator – great outcomes are expected.” Today’s differentiator is “Patient experience.” So, we need to become more knowledgeable about what it is and how to manage it.

“The sum of all Interactions…”
This portion of the definition of patient experience will be familiar to Emergency Physicians. Even though our EM group is frequently held contractually accountable for patient service satisfaction scores, the truth is that we are just a part of the total patient experience. No matter how good we are, all it takes is a dust bunny in the corner, a brusque remark from the x-ray tech or a botched lab test to bring down this “sum” to unacceptable levels.  But, life isn’t fair, and we are tasked with managing the “Patient experience.” Let’s not get too hung up here.

“Shaped by an organization’s culture…”
Without question, the words and actions of the leaders and members of the EM group strongly impact the culture of the ED. If the physicians engage in or tolerate gossip, or let their inappropriate humor run out of control, it produces a decidedly different ED culture than if such behaviors are discouraged. If the EM group fails to discipline its members, the ED could conceivably have as many different cultures as it has providers, with each physician free to do things his or her way when on duty. The unfortunate reality is that many of us don’t think much about our ED’s culture, and it is exceedingly rare that we consciously design and manage it. So, where to begin?


Establishing the ED culture begins with establishing the EM group’s culture. No ED cultural attribute survives long without the unanimous support of the Emergency Physicians. Beginning to work on the EM group culture is best facilitated by an objective outsider who is knowledgeable about EM group issues.  When the group tries to do this with an internal facilitator, the process is often perceived as being dominated by the group’s leadership or its more vocal minorities. This tends to diminish the authenticity of the end result. EM group culture is the sum total of its mission, vision and values, and the leadership competency of its members. So, this is where the process of EM group culture development needs to be focused. Defining your EM group’s mission, vision and values will yield little benefit if the group’s members don’t also have the leadership competency to authentically embrace and demonstrate them.

Have-Do-Be is one construct used to explain the cultural transformation that must occur in individuals in order to transform the group’s culture. In the beginning, the group must decide what it wants to “have” – its mission, vision and values. Next, each individual must learn what he or she must “do” so that the group can realize the “have.” Like a new exercise at the gym, it’s likely that this “do” will feel awkward and stilted at first, but with time, practice and perseverance, the initial conscious effort of the “do” will become the unconscious, effortlessness of “be.” Your group members will automatically “be” people who are much more respectful of patients and their peers who don’t gossip, who honor time commitments and deliver on promises when these expectations are made explicit.

Most EM groups require some initial training in basic relationship management and communication skills prior to addressing mission, vision and values. Physicians are not known for their abilities to work effectively as part of a team, to clearly communicate with their colleagues or to efficiently manage their time. Yet, all of these capabilities are essential to the development and maintenance of a culture of individual and EM group empowerment and accomplishment. The optimum beginning for this process is a two-day, off-site retreat format where the first day is spent on an introduction to relationship, communication and project management skills, with the second day being devoted to mission, vision, values and strategic planning. This should be followed by 3, 6 and 12 month 4-6 hour reviews and refresher sessions to reinforce the principles and to re-energize those who have tried to implement the new behaviors but failed.

Soon after the EM group begins the process of transforming its own culture, a similar exercise should begin with the entire ED staff. It may take a year or two to complete this journey, and no shortcut, to date, has proven itself worth the effort. So, be prepared to be patient and persevere.


“That influence patient perceptions…
The operative word here being “perceptions.” As physicians we tend to be literalists: broke- not broke, in-out, etc. “Patient perceptions” are difficult for us to get our arms around. And it doesn’t help that the definition of “good service” is a little like the problematic definition of pornography; it’s hard to define but we know it when we see it. If you think about the last time you stayed at a five star hotel, what were the things that stood out for you:

  • There was sufficient staff to provide good service.
  • The staff was always engaged and actively looking to see if you had a need so that they could immediately address it.
  • If you looked lost, someone approached you and asked if they could help.
  • Everyone was respectful and deferential to you, the customer and your family.
  • Everyone smiled and went out of their way to say hello and wish you a good day.
  • If you needed information, the staff went out of their way to get it for you.
  • There was a general sense of urgency about minimizing anything like waiting that might inconvenience you.
  • There was no judgment as to whether your needs were “legitimate” or not.

These staff behaviors, along with other things such as the physical surroundings and amenities, made up the sum total of your experience with the hotel, and though it might have been a bit painful at checkout, you likely didn’t regret the price of your stay.

Our challenge is to duplicate such a culture of service in our EDs.

“Across the continuum of care…
This last phrase of the definition of patient experience reminds, us once again, that no matter how hard we work at it there will be things that are beyond our control. A surly hospitalist, a referral physician who can’t see the patient in follow-up for two months or a miscommunication about an outpatient test can negate all of our efforts. Nevertheless, this is a percentages play, and
the more we can exceed the patient’s expectations, the less likely that a minor slip up will run them off.

As the old Chinese proverb says, “A journey of a thousand miles begins with but a single step.” Delivering a top quality “Patient experience” is, as my old partner David Pillow used to say, “a mountain without a top.” Is it time for your EM group to take the first step up?

Ronald A. Hellstern, MD, FACEP
Principal, Medical Practice Productivity Consultants


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