Boy, if there's one thing that ER docs are coming to hate, it's Press-Ganey. The tales of its misuse by poorly informed managers are legion. Dr Brenner had another frustrating one yesterday :
Dr. Brenner's Thoughts on Healthcare: My own private Press-Ganey HellI started a new job in January, and from the get-go had great PG scores. Of course, the sampling was low, so nothing was statistically significant. Once I got one unhappy patient, it killed my score. So 4 excellent scores and 1 bad one = Very bad PG score. But despite that, my scores were still in the top 80%. And stayed that way until June.
All of a sudden, in June my scores dropped to 1%. I naturally assumed I must have gotten a bunch of really bad reviews. Bad luck? Bad day for me? I didn't know. We have a binder that has the recent PG reviews for the department, and looking in there, all the reviews were 5's. The highest. I didn't get it.
The inevitable happened. My administrator saw my scores and insisted I be rehabilitated.
Boy, that's painful. And I won't reveal the kicker, but it gets worse. So whose fault is this? Is it the fault of Press-Ganey? Well, maybe. Data collection is a finicky business, and the results are only as good as the process that brings them forth. But I would contend that the fault lies not in the data itself, but in that of her medical director and hospital administration, who seem to be afflicted with that common disease of statistical innumeracy. Can an "n" of five give valid information on an individual practitioner? Of course not! It's stupidity itself to try to break down the results to such a level of detail with such a low sampling model.
We use P-G ourselves, and with 110,000 visits and a relatively high sampling ratio, we still don't get enough information on each doc to provide meaningful practitioner-level ratings. We distribute them, for informational purposes, but we don't use them in any way at that level. There's been talk about incentivizing docs to provide exceptional service by incorporating P-G into the compensation system somehow. I'm a huge believer in the theory that you get the behavior that you incentivize, so I am interested in the notion. But it's a ludicrous impossibility without cleaner, more valid data that quite honestly does not exist.
There's a clear sentiment in Dr Brenner's post, as well as the rantings of multiple other ER bloggers out there, that the whole notion of "patient satisfaction" is wrongheaded and perverse. For example:
How Press-Ganey is changing medicineI've always practiced that educating your patients in the ER is the best medicine. Whether on nutrition or the nature of their disease process, my patients always appreciate it. Or so I thought. Now I'm being told that my patients don't want to hear that. They don't want to be told to quit smoking. [...] They want that prescription for a z-pack. They want their vicodin. They want that head CT or that MRI and especially that foot xray for that stubbed toe.
Sorta. I agree that patient's agendas when they come to the ER can be ill-informed, and we make it clear to our ER docs that we do not want them handing out inappropriate prescriptions (etc), and that we will back them up if we receive patient complaints that pertain to that sort of thing. However, 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 out 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.
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.
The other elements relate more to the human factor: how does your staff interact with patients? It's pointless and wrongheaded to single out and stigmatize individual providers for "failing" their P-G, but it is useful and productive to emphasize to all the staff, from Doctors to Unit Clerks and Registrars, that these factors matter, and that patient satisfaction is important. Providing education and reinforcement to all staffers for such things as "active listening" techniques, developing scripts to standardize certain communications, and teaching your staff what sort of things patients tell us they care about all are fundamental to improving your department's scores.
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.
How do I know this? We've lived it. A number of years ago, I'm not proud to say that our ER was the worst in the nation in P-G scores: the 1st percentile. Rock bottom. Nothing like sitting down with your CEO and explaining why you're the worst ER in the whole country to give you some incentive to improve. So we set about a comprehensive improvement project. It has taken years, but we've turned the corner. It also takes partnering with the hospital administration. There may be a need for additional resources: If the ER is so understaffed that nurses can barely provide safe patient care, it's going to be hard for them to spend time getting warm blankets. If half the beds are full of boarded patients, then wait times will remain long and scores will never improve. And so on. And it also takes an understanding of how to read and how to use the data. A few years back, we hired a doc whose individual P-G scores at his old hospital were always in the 99th percentile. When he came to us, his scores plummeted to near our physicians' group average. The moral to that it that it's the institution as much or more than the individual that determines how a provider will be ranked.
"You can't manage what you can't measure," is the old management aphorism. P-G is imperfect in many ways. But it's a useful yardstick for comparing one ER to another, and more importantly for comparing your ER today to your ER last year. Ultimately, Press-Ganey is just a tool, one among many. It can be used well, poorly, or not at all. My experience, from a management perspective, is that it can be a valuable part of an overall process improvement initiative in the ER.
