One of the first — and sometimes only — place patients experience a hospital is the emergency department, where many first and lasting impressions are made. It’s known as the hospital's front door, but the ED is also the front line of care, concierge desk and the gateway through which the bulk of admissions enter. As a result, patient satisfaction in the ED isn’t only important to that department, but also vital to the reputation and financial stability of the hospital itself.

By championing a shift to a more patient-centered culture and holding C-suite members accountable for driving that change, board members help patient satisfaction in the ED and ultimately strengthen the hospital overall.

Evaluating EDs

Before exploring any changes, however, it’s important to first understand ED patient satisfaction scoring. First, it’s not standardized. Unlike the inpatient experience, in which all participating hospitals use the Centers for Medicare & Medicaid Services HCAHPS survey, there is no single survey for patient satisfaction in EDs. A CMS survey is in the trial phase, but currently hospitals elect to use a survey method from one of several companies: Press Ganey, National Research Corp., Gallup and others. This makes it difficult, if not impossible, to fairly compare ED scores across organizations. Nevertheless, the results of an individual ED’s selected survey can be helpful in charting its own progress.

Second, while the quality of care in the nation’s EDs is excellent, overall, patient experience scores have remained flat or have declined. In other words, patients have increasingly higher expectations for emergency department service and care.

For patients, the heart of the ED experience is efficiency and communication — two factors that ED staff can take immediate, decisive action to improve. What’s more, improving one often spurs improvement in the other, supporting a reliable cycle of lasting change.

For example, when an anxious patient presents in the ED, crucial milestones include triage, bed assignment, physician encounter, lab or X-ray work and results, and discharge. When these events occur promptly, patient flow is improved which, in turn, allows physicians and nurses to spend more time communicating with patients — a win-win for patient satisfaction.

That said, there is only so much time that can be squeezed out of ED visits, and delays and bottlenecks do happen. When they can’t be avoided, communication is key; simply making the patient aware of turnaround times with labs, X-rays and other services, as well as unexpected delays, can improve his or her impression of the experience.

Improvement Opportunities

To improve efficiency and communication with patients, ED staff can take several steps. The board should request updates on how patients respond to these changes.

• Make the environment more engaging and appealing. A well-lit and clean ED can influence the patient experience immensely.

• Stow or, if storage space is limited, organize medical equipment. For patients, the ED’s appearance suggests the quality of care they will receive, and a disorganized patient care area will chip away at their confidence in their care.

• Create patient champions on staff. In emergency medicine in particular, assigning a patient safety or patient satisfaction champion from the nursing staff who can identify and resolve problems will help to keep communication flowing with patients.

• Assign a scribe to accompany physicians. Scribes are trained medical information managers who enter information into the medical record during the patient encounter. They can be especially useful in larger facilities and in those with inefficient or cumbersome electronic health records. While a scribe enters data into the EHR, the physician can face the patient. When the physician is more focused on engaging the patient and less concerned about documentation, the patient feels better about the visit.

• Institute a comfort care program. Designate a scribe, tech or volunteer to routinely check on patients throughout their stay. While these nonclinicians cannot answer medical questions, they can increase a patient’s comfort by offering to find a family member, providing a blanket or responding to another request. This reassures the patient that he or she hasn’t been forgotten behind the curtain.

Driving a Culture Shift

How can hospitals implement these changes? As with any organizationwide culture shift, it must start at the top. The directive to improve patient satisfaction in the ED has to come from the board to the C-suite and reverberate throughout the entire institution to create momentum for change. Once the board sets the strategy, the CEO needs to deliver this message to staff and empower managers to educate and change processes.

It’s important to remember that ED satisfaction scores won’t improve by making improvements only within that department. The ED depends on the interplay of hospital departments and other on-site experiences. Parking, restroom cleanliness, the efficiency of the radiology department and the length of time it takes to move an admitted patient to an inpatient unit all influence patient satisfaction.

The board is responsible for leading the campaign to improve patient satisfaction. When trustees ask questions and challenge hospital leaders, they make the issue a priority. That endorsement gives the administrative team the impetus to attack the situation. Four questions can help the board to identify sources of patient dissatisfaction.

1. What are trends in longitudinal data saying about our organization? Patient satisfaction scores, if looked at in isolation, are difficult to understand. The data need to be longitudinal and analyzed within a larger context to make sense. For example, patient satisfaction often decreases as hospital volumes surge. Identifying those trends and influences can help boards to home in on solutions, such as changing nurse or physician staffing ratios.

2. What are our key performance indicators? The most common indicators are length of stay for discharged and admitted patients, walk-out rates, times from arrival to registration to bed to physician to decision to departure, and ancillary test turnaround times. A dashboard with all these indicators should be included in materials for every board meeting.

3. How are our physicians and nurses functioning? Are staffing ratios appropriate? Are all providers experienced in emergency medicine? Do they have strong leadership? Because nurses have more touch points with patients than do physicians, it’s important to know how the nurses are performing and how those scores are trending. Here, longitudinal data can help managers and executives to make better decisions about staffing and staffing ratios, communication plans and best practices.

4. What environmental services resources are available in the ED? Making clean, pleasant facilities a priority may seem ancillary to providing quality care, but the newly empowered consumer would disagree.

For many patients, the ED is their first experience with your culture, caregivers, staff and facilities. It is up to the board to set the expectation that each experience be a positive one. 

Derik King, M.D. (, is president and CEO of ECI Healthcare Partners, Traverse City, Mich.