“Nothing satisfactory about patient sat surveys”

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altPhysician activist Ron Elfenbein, MD, sounds off on how patient sat scores are bringing the emergency department to its knees.

I just bought a brand new car. As I was about to drive away, the dealer reminded me that I would be receiving a survey in the mail. He asked that I be sure to fill it out and send it back as his, “future depends on it”. I could not help but think of many of my colleagues who say the same thing to their patients upon their discharge.
Emergency medicine is the youngest specialty and we (and those before us) have fought long and hard to gain acceptance and legitimacy. We demand to be taken seriously, yet we have become beholden to outside forces that dictate our every move. How can we expect to be taken seriously, let alone take ourselves seriously, when we allow patient satisfaction (“patient sat”) surveys to tell us how well of a job we are doing? I am not implying that we shouldn’t care about what our   patients think of us, but rather that our number one priority should be to provide good, honest, care and do the best, at all times, for all our patients. Hospital administrators place excessive stock in these scores, and to what end? I can see rationale for clinical outcome measures as we should always strive to improve upon our mortality and morbidity rates, but not only do patient sat surveys not improve care, they threaten to bring the system to its knees. Here’s how:
Problem #1: 
You can’t please everyone
Let’s face it, sometimes EPs have to be the bad guys, and there’s no way around it. We have to tell the drug addicts that they won’t be getting any more Percocets. That’s not going to go over well. We have to tell the patient with the hangnail that he’s going to be waiting for hours, or worse, that he shouldn’t have come to the ED in the first place. He may be a bit frustrated. What happens when it becomes our priority to make these individuals happy? When we bend our knee to patient sat surveys we risk becoming beholden to drug addicts and serial abusers of the system.
Problem #2:
Don’t mess with triage

If you really want to improve your EDs patient sat numbers, you should focus your attentions on those patients who will actually receive a survey, right? The problem is that patients who are admitted, i.e. the sickest patients, don’t receive surveys; it is the less acute patient who gets one. Therefore, patient sat surveys put direct pressure on EPs to see the sickest patients last and the less acute first. Rather then educating the people who inappropriately utilize our services the surveys simply encourage them to keep coming back.
Problem #3:
Legitimizes system abusers

We have a national problem in the United States — ED overcrowding—due in no small part to individuals using the ED for primary care services, knowing that they won’t be turned away. Patient sat surveys send a clear message to these system abusers that the ED is here to serve them, in whatever capacity they choose. “Thank you for seeking care at our hospital,” we say, “we want to know what your experience was like in our ER for the toe pain you have had for six years. How were you treated? Was the waiting room nice? Was the triage staff appropriate? Please come back and see us again!”
Problem #4:
Salaries tied to surveys

I care about my patient sat survey scores because I am told to by my boss. More important, however, my bonus is directly tied to my patient sat scores. So now my salary is, to a great extent, being determined by drug addicts and other abusers of the system who know nothing of the quality of care I provide. All they know is that they spent four hours waiting to be seen only to have me tell them that their “cold” is indeed just that. They want their antibiotics and/or Percocets and, of course, are not happy they waited and left empty handed.
Problem #5:
Misspent funds

Hospitals are going bankrupt (see Prince George’s County hospital in Maryland) because of declining or non-existent reimbursements. And yet emergency rooms are bursting at the seams with individuals seeking routine care. And still, hospitals spend millions every year on patient sat surveys. Can these expenditures be validated with real results or are we just throwing money at the problem? I submit that patient sat scores tell us nothing of real use, and we ought to redirect these funds.
Problem #6:
Sat scores have become a game

What does it say about patient sat scores that emergency departments hire “Patient Sat experts” who teach physicians little tidbits to get their scores up. This entire scoring system has become a game. These consultants feed us lines to say, tell us to hold the patient’s hand, bring them a soda, a  sandwich, and legitimize their complaints and those of their family. Basically, give the patient what they want, anything to get your scores up. Many EDs even pay people to make follow-up phone calls to raise their scores. When did patient satisfaction become so much like the scoring on American Idol?
It’s time for a change!
What gets my ire up are hospital administrators and their lobby groups. They are the first ones to stand up and complain about ED overcrowding, yet they directly encourage it by relying heavily on patient sat scores. You want to cure this problem? First, eliminate patient satisfaction surveys. Second, institute advanced triage. Put a nurse, PA, NP or EP in triage (depending on comfort level) to do a medical screening exam. I know we already triage, but we need to take it one step further. Those who are sick or potentially sick should be brought right back to the ED; those who are not should be educated! They should be told that the ED is happy to provide treatment, but that there is a co-pay, payable in advance. They should be provided with a list of alternative free clinics in the area for them to consider. By doing this, the overcrowding problem is fixed, EMTALA’s requirements are satisfied and the liability is not any worse than it is now (patients were screened, offered admission to the ED and given alternative, more appropriate venues at which to seek care).
All of that said, we cannot legitimately stand up and complain about any of this because we have sat back and watched it happen. Our complacency implicates all of us and we have thus lost the moral high ground. We are being encouraged to prescribe inappropriate medications, change the way we triage and treat patients, perform minimal to no real education and encourage people to keep coming back to the ED for their primary care. This, I am sorry to say, is the reality of modern, community emergency medicine. We should be ashamed of ourselves for allowing our profession to sink this low, for allowing administrators to dictate how we practice, how we prescribe and how we care for our patients. Mostly, we should be ashamed for what this has done to our emergency rooms in the guise of increased wait times, overcrowding, hospital closures and, according to every recent study on the subject, wholly inadequate preparation for any natural or man-made disaster. In short, we have failed the American people, and I for one am ashamed and embarrassed. We have no one to blame but ourselves. This was not what I signed up for when I entered the field of emergency medicine, I will tell you that.
I would argue that as the “front line” in the health care system, we have a greater responsibility to the population as a whole. If the politicians and hospital administrators will not fix this problem, we need to stand up, exercise some leadership and do so ourselves.
Ron Elfenbein, MD, assistant director at Harbor Hospital in Baltimore, recently campaigned to become a Maryland state delegate.

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