Patient Sat: Rules of engagement

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Whether you love or hate patient satisfaction surveys, there are a few ways to avoid survey biases and make the most of the your numbers. 

The long standing debate over emergency department patient satisfaction survey scores is whether they accurately measure the care provided to patients in emergency departments. Regardless of your position on the issue, there are definitely some statistical biases that are introduced into the process which may negatively impact your scores. Consider the following aspects of the survey which can help increase accuracy and help optimize your patient satisfaction scores:
Misdiagnosis of peer group
Hospitals generally select a “peer group” which is a collection of hospitals sharing certain characteristics (such as geography, patient volume, academic status, etc…) against which they wish to be compared. I’ve found some hospital clients who had placed themselves in an inappropriate peer group – like the ED who had swelled to an annual patient volume of over 50,000 but was still categorized in the 30,000-40,000 annual volume peer group. As EDs with lower volume generally have higher patient satisfaction (Emergency Department Pulse Report 2007, Press Ganey), this ED was receiving a lower ranking than it deserved. When they changed their peer group to the 50,000 + volume peer group, they found their ranking had increased by nearly 30 percentile points. Identify which peer group your hospital is using and make sure it reflects the appropriate comparison hospitals, either by volume or market competitors.

Sample size matters
Most hospitals do not send surveys to all patients and will contract with satisfaction vendors to send out a specific number of patient surveys each month. Some may even target the absolute minimum number of survey completes required under HCAHPS (Hospital Consumer Assessment of Health Providers and Systems), which is 300 per year. For a 30,000 patient/year ED, this would represent 1% of your total patient volume, and would be increasingly less as the annual volume increased (hardly a representative sample!). Be sure to monitor your surveyor’s response rate, which should ideally be no lower than 7-8%. If it is, you should consider increasing the number of surveys sent to patients.


Time is of the essence
Depending on when and how often demographic data is provided to the survey vendors, it may take anywhere from 3-8 weeks from patient date of service until the survey is received. The further away from the date of service that the patient receives a survey, the less likely they are to remember important details (except perhaps negative ones) or even complete a survey at all. It is important to understand how often your hospital provides the vendor with the demographics needed to mail out a survey – daily, weekly or monthly? If it is monthly, odds are that the patient who had a positive experience has forgotten the experience and the unsatisfied patient still remembers every detail and is standing by the mailbox waiting to receive the survey.

The patient is in
ED patient satisfaction surveys are usually sent out to discharged patients. Does this mean that admitted patients whom you’ve spent significant time with at the bedside aren’t included in your score? The answer is yes. However, hospitals generally have at least one question (if not more) on the inpatient survey asking how their care was if they were seen in the ED. Don’t forget to get the results of those ED-related questions on the inpatient survey as you may just find that there are grateful patients who gave the ED physician high marks in the course of their admission to the hospital.

And the question is…
Satisfaction vendors have standard questions which appear on every survey that is sent out, regardless of the hospital. They also maintain custom questions, which may ask about a specific service or aspect of the care provided, such as the convenience of the parking lot or the friendliness of the Pediatric ED. As a client, you have the option of adding such custom questions to your survey in order to better understand the level of patient satisfaction related to a new ED area, program or amenity. While these do not count towards the overall peer ranking, they can help to highlight the impact of specific components of your operation.

So if you have patient satisfaction scores or rankings that don’t quite seem to reflect the level of service that’s being provided, open up a dialogue with the hospital manager in charge of patient satisfaction to get clarification on the above items. Before entering the battle of patient satisfaction, be sure to know the rules of engagement!
Eric Bachenheimer is the Director of Client Solutions for ED Solutions, the consulting/advisory arm of Emergency Medical Associates. Eric can be reached at



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