*With the exception of programs from the ACCEL series, each of which qualifies for up to 4 Category 1 CME credits.
Audio-Digest Emergency Medicine
Volume 30, Issue 13
July 7, 2013
Patient Satisfaction Edward Massey, MD
Quality Improvement and Patient Safety Steven K. Polevoi, MD
The following is an abstracted summary, not a verbatim transcript, of the lectures/discussions on this audio program.
Emergency Medicine Program Info Accreditation InfoCultural & Linguistic Competency Resources
Patient Satisfaction and Safety
The goal of this program is to improve patient satisfaction and safety in the emergency department (ED). After hearing and assimilating this program, the clinician will be better able to:
1. Practice effective strategies to improve patient satisfaction.
2. Communicate with patients in a clear, compassionate, and empathetic manner to resolve potential conflicts.
3. Identify common themes that characterize unanticipated deaths related to an ED visit.
4. Implement strategies to prevent adverse drug events when using software for computerized physician order entry.
5. Educate patients on their diagnosis, expected course of illness, self-care instructions, and return precautions after discharge.
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and the planning committee reported nothing to disclose.
Edward Massey, MD, Attending Physician, Emergency Department, Cedars-Sinai Medical Center, Los Angeles
Satisfaction: defined as contentment derived from having reality meet expectations; emergency department (ED) physicians challenged with minimizing discrepancy between expectations of patients and realities of ED; inflated expectations often compounded by lack of understanding of limitations of ED services and medical technology; physicians must work with societal norms for success; wide gulf exists between strategies of customer service and actual behavior by staff who provide patient care; initiatives for patient satisfaction in best interest of health care providers and make their jobs easier; meaningful and lasting changes intrinsically motivated
Patients vs customers: authors of Leadership for Great Customer Service suggest continuum with patients and customers on each end; patients — perceived as acutely ill (time-dependent condition) and reliant on technical expertise of physicians; purpose clear and active management needed; physician in control and clinical satisfaction higher; customers — often perceived to have higher expectations than patients; expect excellent service and clinical care; customer satisfaction often based on quality of customer service rather than quality of care
Communication: explain facts in clear, rational, and scientific manner; talk to patient about expected ED course and typical wait times with added 30% buffer (allows patient to feel more involved in process and happier with lengthy wait); suggest to patients that period of observation in ED necessary to confirm safe discharge or to determine whether higher level of care required; revisit patient with update of test results and re-evaluate their condition
Stress: important and useful to energize and motivate performance; however, unbearable stress can become distress; recognize personal stress level and be cognizant of personal “hot button issues”; patterns of patient behavior may provoke irritation, regardless of stress level; expressing disappointment or frustration with patient at introductory stage of relationship can poison future interactions; hold criticisms until rapport developed; author of Love Your Patients! suggests presenting criticisms in “feedback sandwich” between two compliments
Conflict resolution: usually best to acknowledge fears or criticisms (even if they appear unreasonable) of disgruntled patient; act of affirming patient’s concerns can improve patient’s perception of interaction; identify expectations of patient and offer reasonable alternatives; actively listen to complaints; lower your voice if patient shouts; use positive body language (eg, uncross arms, open hands, sit down, use sympathetic facial expressions); do not interrupt or resist patient; restate patient’s concerns and offer apology; relying on empathy not advisable; expressing compassion (eg, physically) better strategy; appear more empathetic through animation (eg, nodding head, moving hands, changing facial expression); physical contact (eg, two-handed greeting, hand on shoulder while auscultating, leaning in while talking) shown to improve patient satisfaction; speak personally (eg, in first person) when talking with patients; demonstrate active attention (eg, eye contact) and active listening (eg, restate what patient has said); courteousness most simple and direct way to show respect; goal to acknowledge concerns and frustrations of patient and offer amelioration of problems; speak in plain English (avoid using medical terminology); show interest in patients as people rather than just disease states (eg, briefly ask questions not related to health)
Conclusions: physicians and nurses can work differently to improve patient satisfaction; strive to improve patient satisfaction to benefit well-being of health care providers in ED
Quality Improvement and Patient Safety
Steven K. Polevoi, MD, Clinical Professor of Emergency Medicine, Medical Director, Emergency Department, University of California, San Francisco, School of Medicine
Landrigan et al (2010): looked at temporal trends in rates of patient harm resulting from medical care; analyzed progress of patient safety efforts in subset of US hospitals during past 12 yr; retrospective chart review performed in 10 hospitals in North Carolina (selected because perceived to have great engagement in patient safety efforts); study looked at 100 admissions per quarter from 2002 to 2007; clinical clues of patient harm included administration of antidotes and unplanned transfers to higher level of care; study found 25.1 patient injuries per 100 admissions; majority of patient injuries from problems with procedure or medication; injuries varied widely in severity, from minor problems to death; study found no change in rate of patient harm over time; conclusions — patient harm common in hospitals in North Carolina; reduction in harm difficult to achieve; implementation of more evidence-based practices recommended to improve patient safety, eg, computerized physician order entry (CPOE), reduction in work hours for trainees and staff, bundles of care (eg, sepsis bundles)
Jha et al (2012): looked at long-term effect of premiere pay for performance (PFP) on patient outcomes; PFP attempts to reward providers and hospitals for achieving certain quality metrics (with penalties for failure); 253 hospitals across United States that participated in PFP compared to >3000 control hospitals not using PFP; study looked at 30-day mortality (from 2003 to 2009) in patients with acute myocardial infarction, congestive heart failure, pneumonia, and coronary bypass surgery; conclusions — no difference in 30-day mortality between hospitals that use PFP and control hospitals; hospitals that performed poorly at baseline had no improvement in 30-day mortality when PFP implemented; no current evidence that PFP leads to decrease in mortality; PFP systems improve process measures (eg, administration of antibiotics, preventive measures against nosocomial infection), but have not yet been shown to improve hard outcomes (eg, mortality); process improvements not directly proportional to outcomes; financial incentives may not be large enough
Sklar et al (2007): attempted to determine frequency and causes of unanticipated death within 7 days after discharge from ED; 149 deaths identified in 10 yr (1994-2004); ≈50% of deaths unrelated to ED visit; potential contributory medical error found in ≈60% of cases of unanticipated deaths related to ED visit; common themes — unaddressed abnormal vital signs (eg, unexplained tachycardia; found in 83% of all patients); decompensated chronic disease; atypical presentation of rare disease; mental illness and substance abuse; conclusions — death shortly after ED discharge rare; addressing abnormal vital signs may prevent catastrophic outcomes
Guttmann et al (2011): studied association between waiting times in ED and mortality and hospital admission after discharge (within 7 days of ED visit); in high- and low-risk patients, increasing length of stay in ED associated with incremental increase in risk for death and admission after discharge; no increase in adverse events among patients who leave ED without being seen by physicians; conclusions — adverse events associated with increasing length of stay in ED for discharged patients; time targets on length of stay in ED clinically justified; efforts to improve timeliness of care in ED will likely have positive impact on outcomes of all patients
Metzger et al (2010): study performed in 62 US hospitals that use CPOE and decision support; objective to determine frequency of adverse drug events (ADEs) averted with decision support software; test orders and fictitious patients loaded into software program; detection rates of programs ranged from 10% to 82% (best programs, 71%-82%; worst programs, 10%-18%); 47% of drug orders that would be fatal to patient went undetected; conclusions — detection rate of ADEs vary greatly with decision support among sites and software packages; information technology staff must refine decision support software for particular hospital; authors recommend sharing of libraries of decision support software among hospitals
Fenton et al (2012): study of patient satisfaction, health care use, expenditures, and mortality; looked for linkage between patient satisfaction with primary care physicians and patient outcomes; assumed that satisfied patients more compliant with physicians and should have better outcomes (never proven); study found patients with highest satisfaction had slightly fewer ED visits but increased inpatient admission, health care expenditures (eg, prescription drugs), and mortality rate; conclusions — more discretionary care to improve patient satisfaction may lead to higher mortality rate (due to risks associated with tests, treatment, and hospitalization); does not suggest that physicians should ignore patient satisfaction; however, relationship between patient satisfaction and outcome still poorly understood
Hastings et al (2011): telephone interviews with patients aged >65 yr done within 72 hr after ED discharge; assessed understanding of ED diagnosis, expected course of illness, self-care instructions, and return precautions; looked for association between level of understanding and adverse events (ie, repeat ED visits, hospitalization, or death within 90 days of discharge); 41% of patients had emergency severity index level 2 on arrival to ED; 91% of patients received written and verbal discharge instructions; 16% to 63% of patients did not understand ≥1 aspect of discharge instructions; conclusions — substantial portion of elderly ED patients do not understand discharge instructions and trend toward increased risk for adverse events; new strategies needed to improve communication within this population; speaker recommends calling patients 1 to 2 days after discharge to avert adverse events
Dr. Massey spoke at the 10th Annual Emergency Medicine Symposium — A Practical Update, held December 7, 2012, in Los Angeles, CA, and sponsored by Cedars-Sinai Department of Emergency Medicine and the Office of Continuing Medical Education. Dr. Polevoi spoke at Topics in Emergency Medicine, held November 12-14, 2012, in San Francisco, CA, and sponsored by University of California, San Francisco, School of Medicine, Department of Emergency Medicine. For future CME activities by these sponsors, please visit www.cedars-sinai.edu and emergency.ucsf.edu/education. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.
Brunette DD et al: Implementation of computerized physician order entry for critical patients in an academic emergency department is not associated with a change in mortality rate. West J Emerg Med 2013 Mar;14(2):114-20; Caplan GA et al: A randomized, controlled trial of comprehensive geriatric assessment and multidisciplinary intervention after discharge of elderly from the emergency department — the DEED II study. J Am Geriatr Soc 2004 Sep;52(9):1417-23; Courtney M et al: Fewer emergency readmissions and better quality of life for older adults at risk of hospital readmission: a randomized controlled trial to determine the effectiveness of a 24-week exercise and telephone follow-up program. J Am Geriatr Soc 2009 Mar;57(3):395-402; Fenton JJ et al: The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med 2012 Mar 12;172(5):405-11; Guttmann A et al: Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada. BMJ 2011 Jun 1;342:d2983; Hastings SN et al: Older patients’ understanding of emergency department discharge information and its relationship with adverse outcomes. J Patient Saf 2011 Mar;7(1):19-25; Jha A et al: The long-term effect of premier pay for performance on patient outcomes. N Engl J Med 2012; 366:1606-1615; Landrigan CP et al: Temporal trends in rates of patient harm resulting from medical care. N Engl J Med 2010; 363:2124-2134; Longhurst CA et al: Decrease in hospital-wide mortality rate after implementation of a commercially sold computerized physician order entry system. Pediatrics 2010 Jul;126(1):14-21; Metzger J et al: Mixed results in the safety performance of computerized physician order entry. Health Aff (Millwood) 2010 Apr;29(4):655-63; Sklar DP et al: Unanticipated death after discharge home from the emergency department. Ann Emerg Med 2007 Jun;49(6):735-45; Sutton et al: Reduced mortality with hospital pay for performance in England. N Engl J Med 2012; 367:1821-1828; Thompson DA et al: Effects of actual waiting time, perceived waiting time, information delivery, and expressive quality on patient satisfaction in the emergency department. Ann Emerg Med 1996 Dec;28(6):657-65.
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