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Distressingly low patient satisfaction scores spurred staff and administration into action at Trinity Medical Center in Rock Island, IL. As a result of their efforts, their score in the overall physician section of the South Bend, IN-based Press, Ganey Associates national database improved from the 53rd percentile to the 99th percentile.
Some of the steps taken were large, such as the creation of a new position: manager of hospitality services. Others were seemingly simple, such as placing a stool in every room to encourage doctor/patient contact. But they all contributed not only to greatly improved scores but to greater market share and an improved bottom line for the 350-bed hospital.
The first Press, Ganey results were "a surprise to everyone, especially the ED [emergency department] staff," recalls Walter Bradley, MD, medical director of trauma and emergency medical services. "We felt we were doing a pretty good job in meeting the expectations of patients; we were literally shocked." The ED staff consist of nine full-time and nine part-time individuals, he says.
Patients responding to the survey complained that doctors were abrupt and impatient; no one explained why they had to wait so long; follow-up care was uncaring and rude; doctors did not seem concerned; and patients had to ask the doctor’s name. "That was truly not our perception," says Bradley.
Hospital reaction was immediate and dramatic. "From the top on down, the directive came that patient satisfaction was going to be our No. 1 concern," Bradley recalls. "The impetus was given by the board of directors, then from the CEO of the health system, and it filtered down from the [chief operating officer] through all department managers."
Shortly thereafter, Julia Hull, RN, the newly named manager of hospitality services, took the lead on the improvement project. The goal: to meet or exceed the 95th percentile ranking among peer institutions. That was accomplished in three years — from 1997 to 1999. "It was a stair-step process that we felt we could accomplish over three years," she says.
The initial steps involved analysis and interpretation of the patient satisfaction reports to identify top customer concerns. Customer service education was made mandatory by the system board. Hull spent considerable time with the staff of South Bend, IN-based Press, Ganey, studying tools that could be used to develop a new process for identifying opportunities to improve.
Two key tools they used were the priority index report and the correlation coefficient report. "The priority index report lists the highest priorities of our customers," Hull explains. "At the top of the list are those issues where, if you’re not meeting those needs, the customers will decide not to come to your facility again. At the lower end, they may still come back. So we wanted to focus on the top issue. Press, Ganey recommended that we not look beyond the top 15 issues," she adds. (See sample report, below.)
The correlation coefficient report identifies those issues that are highly correlated to patient decisions and where the hospital scores reflect low satisfaction of patients’ desires. "During each quarter, we see what we could we have improved upon," Hull explains. "Alongside that, we also measure the number of responses as well as the percentile rankings among our peers. Then we choose the top five concerns for that quarter," she points out.
Trinity Medical chose the overall theme of "likelihood of recommending," predicting it would be most cost-effective if it succeeded. "We believed that the issue of likelihood of recommending equated with word of mouth," notes Hull. "And we all know that people make decisions on health care based on what they hear from their families, friends, and so on. If they have a good experience, they’ll tell people about that; if they have a bad one, they’ll tell twice as many. Success in this area would be better for our bottom line than any amount of money invested in marketing."
Involving the physicians in the improvement process required three steps, says Bradley. "The first step was education," he explains. "Some of the doctors who looked at the patient comments said they did not reflect patient care. They had to learn that how they interact with patients is part of quality patient care."
The education step had to come before behavior modification, Bradley notes. Working with Hull, he set up one-on-one meetings with every physician over a four-week period. "First, we shared comments about specific physicians with each of them, then we looked at what we could do to truly effect change."
"The reason I had the patient care representative do this rather than me was that this was expected as my role," Bradley explains. "I wanted a neutral third party who had nothing to gain or lose. This made the process very credible in the doctors’ eyes."
The third step was changing processes within the department. "For example, our nurses have a good deal of autonomy," Bradley explains. "If there was an ankle injury, the nurse could order the X-ray. The doctor would read it, then go to the patient’s room — sometimes to the bedside, sometimes to the door," Bradley adds. "He would explain the injury and the treatment, but he never touched the patient or came to his bed. To the doctor, this seemed like good care, but in the surveys, patients would complain the doctor never touched them."
A simple solution was found: placing a stool in every room. "Now, doctors spend the same amount of time with patients — or even less — but they’re perceived as more caring and as spending more time. We encourage a light touch on the shoulder, or a handshake," says Hull.
When nurses come in a patient’s room, they now write their name on a board, as well as the doctor’s name. "These are simple, little things," says Bradley. "Also, nurses often will say, The doctor will be in in a minute,’ when that’s not necessarily true. Patients only get mad when they’re given unrealistic expectations." Now, he says, nurses will be more honest about the likely waiting time.
Hull is pleased with physician response. "By the third year, we achieved 100% attendance by ED physicians," she reports.