Keeping the patients happy


Does it matter if patients are satisfied with the service they receive? Or is it more important to simply provide care that’s clinically appropriate and forget about the frills and courtesies?

At most hospitals, leaders do care about providing a decent experience for patients and families, even if they sometimes fall short of this goal. And they invest a fair amount of time and money conducting surveys to obtain feedback and monitor their level of patient satisfaction.

The granddaddy of them all is the Press Ganey survey, which is used by hundreds of hospitals across the U.S., including Rice Memorial Hospital here in Willmar. The surveys are sent out each month to a random sample of patients, asking them to respond to questions such as whether their pain was adequately controlled and whether they were satisfied with the doctor’s communication. The survey comes in several versions – one for the emergency room, one for adult inpatient care, and so on.

Results are reported in the form of raw scores which also are converted into percentile rankings, giving hospitals some idea of where they stack up against their peers.

Is it a fair representation of patients’ experiences? Well, yes and no.

Press Ganey surveys rely on patients taking the time to fill out the survey and send it in. Return rates consequently are low. Nationally, the response is about 13 percent. At Rice Hospital it’s a little higher, 17 percent, but this is still not very large.

Such a small number of completed surveys can make it hard to draw meaningful conclusions. For instance, if 10 surveys are returned and one gives the hospital bad marks, that single survey response can skew the entire score. And because people are more likely to fill out a survey if they’re really riled or feel strongly about something, a certain amount of selection bias can come into play.

Spend any time reading blogs by emergency-room doctors and nurses, who tend to be on the front line of the intersection between hospital and community, and you’ll discover skepticism – and downright loathing – of the Press Ganey surveys. But let’s not throw out the baby with the bathwater. When Press Ganey results are tracked over time, they often can reveal a trove of useful information on how an organization or a hospital department is doing.

Shadowfax, an anonymous blogger and emergency-room doctor somewhere in the Pacific Northwest, came to the defense of Press Ganey in this recent post. It’s true that patients can become dissatisfied if they don’t get the CT scan or prescription for narcotics they expect, even when it’s clinically inappropriate, Shadowfax writes. In a masterful understatement, he points out that "patients’ agendas when they come to the ER can be ill-informed."


… When you look at P-G feedback in large quantities, the typical complaints or illustrative comments reveal that other factors are the critical elements in patient dissatisfaction. I’ve reviewed hundreds, if not thousands of these comments, and several themes have emerged that provide very useful information on how we can serve our patients better.

To answer the question, What are the key drivers of patient satisfaction? these elements seem to matter most:

– Patients want to be placed in the treatment area promptly and seen by a provider in a timely manner.

– Patients want their doctors and their nurses to be polite and respectful.

– Patients want to feel that their physician listened to them.

– Patients want to feel like their caregivers cared about their comfort.

I don’t think there’s anything controversial on that list. But how do you use it? You design processes and procedures that reflect the patients’ priorities as well as the medical necessities of the ER.

Shadowfax reveals that at one time, his hospital’s ER satisfaction scores ranked in the bottom percentile. Even for hardened cynics, the bottom of the Press Ganey barrel is not a good place to be. But with hard work, "we’ve turned the corner," he writes.

Not that it was easy. If patients are dissatisfied with the time they spend in the ER, it might be because the department is understaffed, or not adequately staffed for peak times, Shadowfax writes. If half the beds in the ER are occupied by patients who are being boarded, wait times can be lengthy unless this issue is addressed. In fact, wait times are the single biggest complaint among ER patients, he says:

The bed-to-door time and door-to-doc times correlate dramatically with the top-level "likelihood to recommend" patient satisfaction score. Patients hate waiting, and I do too, when I have been a patient. Further, this is not an unreasonable expectation on the part of patients. If the wait times are averaging an hour or more, then your ER is underperforming (dramatically) in this arena and it’s predictable that the P-G numbers will reflect that. Whole books have been written about optimizing ER patient flow, so I’ll not belabor the point. Still it must be noted that this alone is probably the single most important factor in overall satisfaction.

From a patient’s point of view, however, even a short wait time and a resolution of whatever problem brought the patient to the ER can be less than satisfactory if the patient feels he or she was rushed through the encounter, or treated brusquely or dismissively. This is the human factor, and it can’t be ignored, Shadowfax says:

Remember that when patients talk about their "comfort" that they are not necessarily talking about narcotics. That’s a common assumption in this age of frequent fliers and drug seekers. To the average patient, the ER is a bewildering and uncomfortable place to be. Little things like getting the patient a warm blanket, a pillow, pulling the curtain for their privacy, or finding a chair for their family member are incredibly important to patients. Telling them your name, or reminding them of their doctor’s name. Again, when you train your staff in these things, when you let them know that they matter and you get buy-in from the caregivers in the ER, then you start to see cultures change, and scores improve.

When these things become embedded in the culture, then a hospital knows it’s doing things right.

Some years back, Rice Hospital’s ER was in a similar situation to that of Shadowfax. While the ER’s Press Ganey scores weren’t at rock bottom, there was room for improvement. Hospital officials took it seriously and embarked on making some changes. These days the Rice ER almost consistently ranks in the 90th percentile in its patient satisfaction scores.

Maintaining this level of patient satisfaction in a busy, fast-paced emergency room is no easy task. Rice’s ER has been especially challenged this year with a rising patient volume that started back in February and has continued through the summer.

You’d think the Press Ganey scores would start to drop under the ongoing stress on the ER’s resources and staff. Instead, the latest round of patient satisfaction surveys, announced last week, showed the ER score actually rose in the past three months. That’s right, the score went up.

Whether you believe in the validity of the Press Ganey survey or not, it’s hard to see these results as anything other than a powerful statement about putting patients first. When the people in Rice’s ER talk about keeping the patients happy, it’s not just feel-good self-promotion. They really, really mean it.

West Central Tribune file photo by Gary Miller