Despite longer wait times, satisfaction still improves

Communication is critical for patients to be happy

In findings that at first glance may seem puzzling, the 2007 ED Pulse Report patient satisfaction survey by Press Ganey Associates indicated that while ED wait times continue to increase, so does patient satisfaction.

The survey shows that the average time a patient spent in the ED in 2006 was four hours, compared with 3.7 hours the previous year. However, overall satisfaction peaked at 83.1% during that same year, compared with a high of 82.9% in 2005. Even more striking, it was only 81.4% in 2003 and has steadily risen since then.

The answer lies in communication, says Matt Mulherin, a spokesman for Press Ganey. "EDs can compensate for wait times going up by providing better service quality in terms of communication," he says. He offers the analogy of an airline that has discontinued meal service. "That may tend to make customers less satisfied, but if at the same time you roll out a new rewards program or offer better communication from attendants, there will not be a drop in overall satisfaction," he says.

In the same way, EDs can compensate for long wait times by improving communications, Mulherin says. The patient typically is a well-informed health care consumer, he says. "They read about rising numbers of uninsured [in EDs], understaffing, and overcrowding," Mulerhin says. "They will have a higher tolerance as long as you are respectful of their time and keep them informed."

Improved communications may not be the only reason for increasingly high patient satisfaction scores, argues Michael Carius, MD, chairman of the ED at Norwalk (CT) Hospital. There also is an increased expectation regarding patient satisfaction on the part of hospital senior management, he says. "This has been impressed on those of us who are middle managers — ED chairs and nurse managers — or else perhaps we might enjoy employment elsewhere," Carius says. "There is also a general sense among all caregivers that patient satisfaction is important by itself, although this has a long way to go."

The 'golden hour'?

ED managers agree that beyond one hour, or possibly two, the effect they can have on patient satisfaction drastically decreases, and that is borne out by the survey results that show satisfaction dropped as wait times increased. (Patients have an 'internal clock,' asserts one ED manager. See the story below.)

Keep the patient's 'internal clock' in mind

Once a patient makes the decision to seek emergency care, their 'internal clock' starts, asserts Alex Rosenau, DO, FACEP vice chair, Department of Emergency Medicine, at Lehigh Valley Hospital and Health Network, Allentown, PA. The time to pain relief, the time to seeing the physician and then to final disposition are all significant points in their treatment journey, he explains. "Many techniques can help the patient to progress through the visit and still obtain a reasonable degree of satisfaction."

Bedside registration, triage staff test ordering, communication with the patient, and assurance from a physician that the patient was not forgotten all help in moving towards the goal and in satisfying the patient, Rosenau continues. "Pain relief is critical, and explanations by each staff member are immensely helpful," he adds.

TV's and phones in the room provide some help in the stable patient, and for their supporting family and friends, Rosenau notes. "Liberal use of the blanket warmer to assure personal comfort and, if appropriate, providing food and/or drink are some of the personal amenities that relieve discomfort and show professional yet personal caring," Rosenau observes.

Finally, he says, how the visit itself is 'orchestrated' can set the tone for a good memory and a successful outcome. "Proper introductions to everyone in the room, listening through allowing a full airing of the patient's story — preferably with at least a few moments sitting at the bedside — answering questions and addressing unstated fears are all appreciated by patients," Rosenau shares. "Proper discharge instructions along with a printout of lab and imaging results to take back to a private physician are not only medically helpful, but are appreciated by the patient and their external medical care provider."


For more information on the patient's 'internal clock,' contact:

  • Alex Rosenau, DO, FACEP, Vice Chair, Department of Emergency Medicine, Lehigh Valley Hospital and Health Network, Cedar Crest & I-78, P.O. Box 689, Allentown, PA 18105. Phone: (610) 402-2273.

If you see the patient after an hour, the key is to apologize for the wait. advises Gregory Henry, MD, FACEP, risk management consultant with Emergency Physicians Medical Group in Ann Arbor, MI. "You never, ever get into a fight with a patient over the wait time," he says.

Apologize first

At Wake Forest University Health Sciences in Winston-Salem, NC, "when our waiting times go beyond one hour, our faculty, residents, and nursing staff know to greet the patient with a simple apology for their wait, and then begin addressing their care needs," says Bret A. Nicks, MD, assistant professor and assistant medical director in the Department of Emergency Medicine. "In addition, when our wait times are several hours, we routinely have someone make an announcement in the waiting area explaining that it is very busy in the ED, and we appreciate their patience and will take care of their medical needs as quickly as possible."

The critical time appears to be two hours or less, Carius says. "Less than two hours and you have an opportunity to intervene," he says. During that time, Carius adds, his staff use handouts to explain the triage process and occasional long waits.

Norwalk has signs in the patient rooms explaining the long waits. (See wording of the signs in box below.) They also have volunteers that carry the messages to the patients and families about the waiting times. "We apologize endlessly for delays that are beyond our control," Carius says. "But, in the end, if the wait is more than two hours, it is a losing battle."

Did You Know?

1. That it takes at least an hour to get all your lab tests back.

2. That it takes at least two hours for the CAT scan dye to get through your system before you can have your tests completed.

3. That if you need any pain medication, you have to ask for it.

4. That if you need assistance, all you need to do is push the call button.

5. That there are pay phones in the waiting room for you to use.

6. That sometimes we draw blood samples at the same time we insert the intravenous in case the physician or physician's assistant orders any tests. This is done so we don't have to stick you twice, but sometimes no tests are ordered so the samples are thrown out. Don't panic, it was only a few tablespoons of blood that was taken. Your body will replenish that before the day is over.

Source: Norwalk (CT) Hospital.

How the patient perceives the wait also is a key factor, notes Henry. "If I say I think a blood test will be back in 40 minutes even though I know it's almost always 20 minutes, I'll be a hero if it comes back in 35 minutes," he explains. No patients complain if you say, 'We're done now, you can go early,'" Henry points out.

It's important for the ED physician to give all patients "anticipatory guidance," Henry says. "We lay out for them a realistic time frame and, when pushed, always overestimate the time," he says. "After all, you get to set the expectations."

Finally, says Henry, it's at least as important to concern yourself with family satisfaction as it is to focus on patient satisfaction. "More [complaint] letters are written to administration by, or prompted by, the family than the patient," he says.


For more information on improving patient satisfaction, contact:

  • Gregory Henry, MD, FACEP, Risk Management Consultant, Emergency Physicians Medical Group, 1850 Washtenaw Ave., Ann Arbor MI 48104. Phone: (734) 995-3764. Fax: (734) 995-2913. E-mail:
  • Matt Mulherin, Press Ganey Associates, South Bend, IN. Phone: (800) 232-8032. E-mail:
  • Bret A. Nicks, MD, Assistant Professor, Assistant Medical Director, Department of Emergency Medicine, Wake Forest University Health Sciences, Winston-Salem, NC. E-mail: