Dr. Welch is the quality improvement director in the emergency department at LDS Hospital in Salt Lake City, a clinical faculty member at the University of Utah School of Medicine, faculty at the Institute for Healthcare Improvement and the Urgent Matters Project for the Robert Woods Johnson Foundation, a quality improvement consultant to Utah Emergency Physicians, and a member of the Emergency Department Benchmarking Alliance.
Part Two in a Two-Part Series
Patients have definite ideas about what they like and don't like about physicians' behavior, dress, manners, and communication abilities, as I discussed last month, but technical skills also affect patient satisfaction.
In one study, patients who received ultrasonography in the ED rather than in radiology viewed the physician as having a more caring attitude, rated the physician as having better skills and ability, and ranked overall satisfaction with the ED visit higher. (Am J Emerg Med 1999;17:642.) Patient satisfaction scores improved as the physicians' skills progressed. There would appear to be no downside in patient satisfaction with the introduction of bedside ultrasonography in the emergency department.
Pain is the primary symptom that causes patients to seek emergent medical care, and the complexities of pain management in the ED are only beginning to be unraveled. Though there is a general correlation between pain relief and satisfaction, this area of medical research is confounded by cultural factors, the intensity of the original pain, and differing pain scales. Add to this the knowledge that a number of quality organizations, including the Centers for Medicare and Medicaid Services, are considering making time-to-pain-management in the ED a marker for quality and performance. Now we have everyone's attention. This area is worthy of a literature review itself, and a few themes in pain management are worth the emergency physician's notice.
Good pain management in children correlates highly with patient satisfaction, and ought to be a focus for departments seeing significant pediatric volumes. (Acad Emerg Med 2002;9:1379.) Patients appear to have preferences and expectations for ED pain management, and these could be easily met. (J Emerg Med 2004;26:7.) Patients under 54 generally prefer PO analgesia, while the more senior the citizen, the more likely he will prefer IV analgesia, though oral medication is still preferred. The more severe the pain intensity reported, the more likely the patient will prefer parenteral medication.
Another study found a slight preference for parenteral analgesics over oral, but the study population was exclusively orthopedic fractures in older patients. (Am J Emerg Med 2000;18:376.) In both studies, intramuscular analgesia was the least preferred route of administration for analgesia in the emergency department. Timely alleviation of adverse symptoms also has been shown to deter patients from leaving before being seen by a doctor. (Ann Emerg Med 2003;42:3.)
In short, your ED should have a well-stocked selection of PO analgesics on hand, and emergency physicians should be very liberal in dispensing analgesics for painful acute conditions. It should be easy to assess in triage which patients need parenteral medication and to expedite IV placement.
Art of Caring
It is becoming increasingly apparent that the art of caring for patients correlates with satisfaction. An uncaring attitude is cited in seven to 13 percent of emergency department complaints. (Ann Emerg Med 1987;16:857.) Caring physicians and nurses are variables that show up repeatedly in satisfaction data and at times even override waiting times as predictors of patient satisfaction. (Acad Emerg Med 2004;11:51.) Put simply, even speed cannot compensate for rudeness, disrespect, or an uncaring attitude.
Because patients perceive that the doctor is spending more time with them when he is seated, many EDs have put inexpensive stools at each bedside to encourage the physician to sit, even for a brief encounter. Although they are unreliable and perhaps unnecessary from a diagnostic perspective, old-fashioned habits from prior generations such as holding a patient's wrist to check pulse or touching a forehead for tactile fever offer a nonverbal cue of caring.
Some institutions have started customer service training programs to improve interactions between health care providers and patients with great results. (J Healthc Manag 1998;43:427.) The most successful and sustained programs involve an institutional commitment to the principles of customer satisfaction and service. (Mayer TA. Leadership for Great Customer Service. [2004.] ACHE Management Series. Health Administration Press. Chicago.)
Another new area showing promise in improving the communication and interpersonal interaction of the encounter is scripting, in which staff is provided with positive dialogue for specific situations in the ED. (Emerg Med Clin North Am 2004;22:87.) If you or a colleague have particular areas that are difficult in interacting with patients, scripting can be an effective remedy for these problems. Scripting can be helpful for distressed family members, phone call requests, drug-seekers, long waits, angry physicians, and complaints.
Research can guide us in enhancing patient encounters to decrease complaints and to improve patient satisfaction. Most of these changes require little cost and only minor changes in habit. Start today: Grab your lab coat and your ultrasound machine, with Percocet in one pocket and business cards in the other, sit next to your patient, touch her hand, and say, “Hello, Mrs. Smith. I am Dr. Jones.”
SKILLS THAT CORRELATE WITH HIGH PATIENT SATISFACTION
▪ Though unreliable and unnecessary for diagnosis, holding a patient's wrist to check pulse or touching a forehead for tactile fever offer a nonverbal cue of caring.
▪ Patients who received ultrasonography in the ED rather than in radiology viewed the emergency physician as having a more caring attitude.
▪ There is a general correlation between pain relief and satisfaction.
▪ Good pain management in children correlates highly with patient satisfaction.
▪ Caring physicians and nurses are more important to patients, at times even overriding waiting times.
▪ Satisfaction scores are higher when doctors sit down while talking with patients.
▪ Scripting, in which staff is provided with positive dialogue for specific situations, improves patient satisfaction.