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News: ED-CAHPS Surveys Take Steps Now to Ease the Future

Scaletta, Tom MD

doi: 10.1097/01.EEM.0000452783.98151.b6

Dr. Scaletta is the medical director of the emergency department at Edward Healthcare in Naperville, IL, which has 90,000 ED patient visits annually and patient satisfaction consistently in the 99th percentile.



Perception is everything. That especially rings true in health care where patient satisfaction scores play a significant role in market position, consumer preference, and the revenue stream. Add to those factors the evolving value-based reimbursement models toward which payers are shifting, and health care organizations suddenly have a highly vested interest in consumer opinion.

Yet many hospitals focus primarily on the inpatient experience, failing to apply the same level of attention to consumer perceptions of the emergency department. That will have to change soon because an Emergency Department Consumer Assessment of Healthcare Providers and Systems (ED-CAHPS) is expected to be mandated by the Centers for Medicare & Medicaid Services (CMS) sometime in 2015. (

ED-CAHPS surveys are not currently required nor are there direct reimbursement ramifications for low ED patient satisfaction scores. The pressure to measure satisfaction, however, will quickly intensify as CMS further defines survey questions and gathers test data to begin the mandatory survey process. ED directors would be well served to prepare now by developing proactive patient communication strategies.

Some within the ED provider community feel patient satisfaction surveys are unfair because they measure perception or opinion rather than actual service. Others believe that satisfaction is somewhat irrelevant because patients in the ED primarily need medical expertise. For reasons such as these, even ED administrators and physicians who are aware of the pending ED-CAHPS have taken little time to focus on what it will mean to emergency medicine.

Just as CAHPS scores now affect hospital care quality, safety, and financial performance, ED satisfaction can have a significant impact on the bottom line. From a business perspective, ED-CAHPS scores are likely to affect a hospital's ability to grow market share and expand services. As indicated by CAHPS, scores also will eventually affect reimbursement rates. In fact, payers may begin to demand certain levels of service for their members and offer better rates for EDs with higher scores as they evolve to value- and population-based payment models. Patient satisfaction also gets the attention of administrators, who themselves are often measured by their ability to demonstrate to the hospital board of directors that patient satisfaction is excellent.

Beyond the business implications, however, emergency physicians also should note that structured patient surveys could help complete the American Board of Medical Specialties recertification process. The board now requires physicians to use an experience of care survey to maintain certification that measures their behaviors in communication, listening, providing information, and demonstrating concern for patients.

It's a simple matter: An emergency physician's schedule seldom permits lengthy patient interactions. The challenge, therefore, is finding ways to affect patient satisfaction scores positively with only minor adjustments to existing workflow.

I view an ED visit as a challenge of twos. Physicians have roughly two minutes during a typical encounter to establish the patient's confidence. They then spend the next two hours doing the appropriate workup, which lays the groundwork for the care the patient will need for the next two days. Establishing a solid patient connection is difficult in a very busy ED, but it plays an integral role in improving patient satisfaction and outcomes, lowering malpractice risk, and enhancing the ED work environment.

Connecting with patients and achieving high ED-CAHPS scores does not mean giving patients only what they think they need. Rather, it involves clear communication. Instead of ordering an unnecessary x-ray or drug, for example, physicians can improve utilization and outcomes and also develop better patient rapport by clearly explaining the negative impact of unnecessary radiation or the risk posed by antibiotic-resistant bacteria. That's why it is so essential to implement tools and processes that strengthen communication within the confines of ED workflow.

On the administrative side, some ED directors have voiced concern that surveys will only expose issues they do not have the time or the resources to address. Yet, taking the time now to evaluate the tools and processes used to communicate with ED patients makes it possible to ramp up for the ED-CAHPS in a way that also enables effective problem-solving. Automated patient communication tools, for example, can provide full reporting on statistically valid measures and areas of improvement, even before ED-CAHPS becomes mandatory.

Despite the logistical challenges of implementing an ED patient satisfaction survey, ED directors can take some steps to prepare:

  • Set realistic goals based on available resources. It may not be realistic for EDs with staffing or facility limitations, for example, to expect patient satisfaction ratings in the 90th percentile. Moving the needle to the 75th percentile from the 50th percentile, on the other hand, is a more achievable goal. ED directors should aspire to the highest possible ratings by using available resources to their fullest.
  • Proactively manage patient expectations. The old adage “under-promise and over-deliver” is appropriate in the ED, and can be done easily. Physicians who know that test results are typically returned within 45 minutes but tell patients to expect them in an hour have just built a buffer zone. Patients' expectations are exceeded and satisfaction improves when results arrive earlier than communicated.
  • Communicate respect and concern even during long wait times. If ED wait times are consistently higher than those of competitors, offset the difference by apologizing for the delay and keeping patients informed. Physicians and other caregivers should immediately acknowledge the wait and show appreciation for the patient's patience. Simply treating patients — and their time — with empathy and respect at every step goes a long way toward high satisfaction.
  • Automate the patient follow-up process. Automated tools can expedite follow-up with discharged ED patients, leading to fewer return visits, better resource utilization, and consistently higher levels of patient satisfaction. Tools such as SMARTworks can sift out open-ended comments that ED directors can use for physician coaching and process improvement and provide statistically valid data for professional recertification and surveys. Automated patient follow-up also can efficiently address lingering patient concerns, often turning a complaint into praise.
  • Supplement third-party-administered surveys when appropriate. A third-party-administered survey is useful for CMS reporting and benchmarking against other institutions. Small sample sizes, the inability to analyze specific care situations, and delays in receiving results can limit the ability of those instruments to create organizational change. Follow-up tools that contact all patients and present results to providers in days instead of weeks can allow for improvements that ultimately boost the more formalized satisfaction scores.

Follow-up data, for instance, might reveal that patients did not feel they were seen in a timely manner. An ED director looking deeper might notice that several patients were admitted concurrently and held in the ED until inpatient rooms were available, which delayed the movement of new ED patients into exam rooms. Once armed with this information, the director could then seek hospital-wide process improvement.

Measuring ED patient satisfaction does not have to be a burden. Instead, the impending ED-CAHPS requirement gives health care organizations a fresh chance to review their approaches to patient communication and patient follow-up to ensure successful results. Physicians and nurses who know they are being measured against patient feedback are more likely to understand the importance of timely and mindful patient-provider communication.

Implementing solutions now that allow the accurate assessment of current satisfaction levels and that identify barriers can alleviate staff anxiety about the coming CMS requirement. Clearly defining an effective approach to patient satisfaction can allow health care organizations to heighten staff satisfaction and the entire ED patient experience.

© 2014 by Lippincott Williams & Wilkins