With Medicare revenues at stake, ED managers place new importance on elevating the patient experience

Keys areas of focus include patient-centric training, throughput times

Hospitals across the country are scrambling to improve patient satisfaction so that they won't be dinged by a provision in the Accountable Care Act that will put a portion of Medicare dollars at risk, based on the Hospital Consumer Assessment of Healthcare Providers and Services (HCAPS) surveys. Beginning next fall, Medicare will withhold 1% of payments so that it can then use this money to provide incentive funds to hospitals that perform well on quality standards and the HCAPs surveys, which query patients on everything from cleanliness and noise to tell how well clinicians listened to their concerns.

Experts say roughly a third of these funds will be connected to patient satisfaction. Further, the percentage of funds that is withheld from Medicare payments will gradually increase to 2% by 2017, so hospitals need to understand that patient reviews will be increasingly important to their revenue base. Also, some commercial payers are incorporating patient experience scores into their payments as well, and the Centers for Medicare and Medicaid Services (CMS) is hoping more of them will follow suit.

While efforts to please patients are hospital-wide, administrators recognize that the front door is critical, so the heat is on ED managers to make sure that patients don't just receive first-rate care when they enter the emergency setting, but that they are also seen by a provider quickly, and that they leave the institution with good things to say about their experience. It's a tall order in an especially challenging environment, explains Jeffrey Gold, MD, chancellor, executive vice president for biosciences and health affairs, and dean of the College of Medicine and Life at the University of Toledo Medical Center (UTMC) in Toledo, OH.

"The ED is one of the most difficult areas because it tends to be very busy, patients tend to be very sick, and people are coming and going," he explains. "However, the same basic principles of caring for individuals apply. There are facility issues of quiet, privacy, access to rest rooms, and things along those lines that make all the difference in a medical environment ... but then you also have to keep waiting times down so that you can get patients through whatever it is they need so that they can go home quickly."

Keep the focus on patients

Patient satisfaction became a hot button issue at UTMC about five years ago when it became clear that there was ample room for improvement in the way patients viewed their experiences with the health care organization. "Frankly, we had focused much more on quality and safety than we had focused on patient satisfaction, so when we got quality and safety where we wanted — although we certainly believe that quality and excellence are a journey, not a destination — we started focusing intensely on the patient experience," says Gold.

To kickstart the process, UTMC established iCare University, a division of UTMC that trains all employees, from the clinicians to the janitors, in skills and techniques designed to elevate the experiences that patients have when they interact with the health system.

"We actually had a ribbon-cutting this fall on a brand new teaching site with mock patient rooms and office settings, as well as classroom settings, but the iCare concept was started in 2007 as a way to bring doctors and nurses and patients, as well as medical students, residents, and others together around the idea of patient centeredness," says Gold. "We have thought for a long time that there is not enough attention to this issue of patient centeredness or the patient experience, so we birthed this idea for the iCare program, which stands for communication, access, respect, and excellence.

To underscore the seriousness of the endeavor, UTMC brought in a director of patient experience to oversee the iCare program, and it distributed iCare lapel pins to all employees. Further, every department, including the ED, monitors a series of metrics on display via flat-screen TVs in all of the inpatient and most of the outpatient units, says Gold.

"Every unit knows how it is doing in terms of patient satisfaction and patient centeredness. [The personnel] know what their goals and objectives are, and we continue to provide real-time metrics back to the individuals who are caring for patients," he explains. "As a result of this, we have seen dramatic improvements in our patient-centeredness scores, and we also continue to have extremely high patient-safety and patient-quality parameters."

Get input from patients

In the ED, one issue of prime importance is keeping the wait time low, says Gold, but he stresses that you also need to make sure that patients and families get all of their questions answered and that they understand what is going to happen. "Then, if a patient is going to be admitted, get him admitted as quickly as possible. If he is going home, make sure that follow-up is arranged, and if he has a prescription that needs to be filled, help him do that as well," he says. "It is no different than if you are going to a bank or getting on an airline or anything else. It is what defines a good customer experience."

While it isn't necessarily easy getting busy clinical staff to focus on elevating the patient experience, Gold says UTMC hasn't received any pushback to the initiative either. He credits the personalized way administrators discuss the program. "We refer to iCare as the way we want to be treated," he says. "All health care providers, including physicians, nurses, pharmacists, and others, are health care recipients, and they want to be treated with respect, dignity, and autonomy, so I think they understand that it is important to treat people in that way."

To ensure that the needs of patients remain a top priority, former patients are constantly invited into senior leadership meetings to discuss what their hospital experiences were like, says Gold. "We are constantly identifying patients who had a wonderful experience here because of this caring focus, and bringing them to senior leadership team meetings so they can talk about why their experiences were good," says Gold. However, he emphasizes that patients who have less than positive experiences are invited to share their stories with leadership as well. "We can learn from those experiences because when these patients tell their stories, it is not the way the nursing, pharmacy, and other leaders want to be treated themselves, so it motivates them."

Speed patient throughput

The Cleveland Clinic in Cleveland, OH, has an office of patient experience, too, and it hosts annual summits on this issue so that hospital representatives can share ideas and strategies that they employ to make sure that the experiences patients have while in the hospital are in line with the first-rate care that they receive. What this has meant for the organization's nine hospital-based EDs is a heightened, laser-beam focus on patient throughput.

"The longer a patient waits, the less well they perceive their experience," explains Donald Moffa, MD, the interim department chair of emergency medicine at the Cleveland Clinic. "That not only reflects on the care they received in the ED, but patients who are admitted through the ED who have had to wait a long time give lower scores in general for their inpatient stay." (Also, see "Take aim at long wait times by mastering the art of cue management," below.)

Consequently, what the Cleveland Clinic is endeavoring to do is shorten door-to-provider times as well as overall length-of-stay for emergency patients. And it is doing this through a new ED system that the organization began to roll out this summer called split flow. "There is an area called 'intake' that we have built in our newly remodeled main campus ED where we staff a mid-level provider who is a licensed independent practitioner, and a nurse," explains Moffa. "Together they go in as a team and assess patients, decide what level of care they need, and then start the workup ... whether it is a blood draw that needs to be done or something else."

In the past, a patient might be returned to the waiting area following an assessment, but with split flow, any needed tests or imaging will commence right away. Further, the assessment team will determine where that patient needs to go to receive care. "We call our split-flow area the split-flow clinic, so if the person is vertical and doesn't need many resources, perhaps he will be sent to get an X-ray and then go to the split-flow area for further care," says Moffa. "However, if the patient is sicker and needs the resources of an acute ED, the clinical team will route him in that direction, where there is an entirely different team of personnel taking care of emergency patients."

The approach is making a difference. When the ED first implemented the split-flow system this summer, the average door-to-provider time was about 47 minutes, and now it is less than 30 minutes, explains Moffa, noting that there has also been an overall improvement in patient perception of care in the ED. In addition, under the new approach, mid-level providers are able to handle about 25% of the ED's daily patient volume, consisting primarily of lower-acuity patients. "This allows physicians to focus more of their time on the acute patients," says Moffa.

Implement rounding

In addition to implementing the new split-flow process, the front end of the ED has been reconfigured so that the patient waiting area is no longer next to the acute side where the ambulances come in. Instead, patients and families wait in a larger, quieter atmosphere that is free from the traffic and commotion that they used to be exposed to, explains Moffa. "Now, it is so quiet that patients don't know what is happening in the main ED, and rightly so," he says. However, a tech or nurse regularly rounds through the waiting area to give patients updates on when they will be seen, as well as to respond to any questions or concerns they may have.

The idea to implement rounding actually came in response to one patient's unpleasant experience of waiting for a long time in the ED with very little knowledge about when he would be seen or what the hold-up was, explains Moffa. "We brought that patient in to describe his experience, got the engagement of staff to develop a solution, and then implemented the solution."

Moffa adds that some of the health system's most valuable information comes from patients in the form of comments that they will return with surveys, or in notes or letters that they drop in the mail. "Some of these things really need immediate attention, so we will bring the people in who have written those verbatims, and we will have them present to staff," he explains.

Consider HEART approach

Similar to UTMC, there is an array of system-wide services at the Cleveland Clinic that can help to burnish ED patient reviews. For example, a healing services team offers aromatherapy, light massages, and spiritual care for patients or loved ones who are stressed or in pain. "It doesn't impact emergency medicine care, but when we have a crisis situation in the ED, such as a family member with a loved one who is in cardiac arrest, we will quickly contact our chaplain or our spiritual healing services to come down to the ED so that they can interact with family members," says Moffa.

Also, all Cleveland Clinic employees, including physicians and nurses, wear a badge that says "Caregiver," and they go through so-called HEART training designed to help them be more responsive to patient concerns. "It is a better means of listening to a patient when they have a complaint or a problem. You have to hear them, empathize with them, acknowledge them, give them a response, and thank them," says Moffa, who helped develop the five-hour training. "It is a way you can take a breath ... and see how you can improve care with the patient or the patient's family, and really impact their experience."


  • Jeffrey Gold, MD, Chancellor, Executive Vice President for Biosciences and Health Affairs, and Dean of the College of Medicine and Life, University of Toledo Medical Center, Toledo, OH. Phone: 419-383-4000.
  • Donald Moffa, MD, Interim Department Chair, Emergency Medicine, Cleveland Clinic, Cleveland, OH. E-mail: moffad@ccf.org.
  • David Eitel, MD, MBA, Co-inventor of ESI Triage, and Co-author of Optimizing Emergency Department Throughput: Operations Management Solutions for Health Care Decision Makers (Productivity Press, 2009). E-mail: daveitel@comcast.net.

Expert: Take aim at long wait times by mastering the art of cue management

There is no getting around the fact that key to a positive patient experience in the ED is time: Patients want to see a provider quickly, and if they have to wait for hours, their view of the episode will be soured regardless of a positive outcome or whether the care they received was of the highest quality.

However, even though this concept is well-understood by ED managers, patient flow continues to get bogged down on a routine basis, and it is easy to see why, according to David Eitel, MD, MBA, the co-inventor of ESI Triage, and co-author of Optimizing Emergency Department Throughput: Operations Management Solutions for Health Care Decision Makers (Productivity Press, 2009). "In most EDs, there is linear processing. The patient comes in, and then you do this, and this, and then this," he says. "Linear processing guarantees waiting. When you have multiple patients or customers vying for a pool of service providers, linear processing is the death knell to flow."

The solution is not typically a matter of hiring more personnel, says Eitel, but rather a bit of sophistication in queuing theory — or put more simply, the management of lines. In fact, Eitel suggests that some ED managers could learn a thing or two from retailers who have developed systems so that no one waiting to be served gets stuck behind a single slow cashier; customers merely move on to the next open cashier. Eitel says this same idea can be applied to a busy ED.

"We don't have one or two servers. We have a whole bunch," says Eitel, noting that there are physicians, nurses, lab technicians, and so on. "Within the system, people can get into cues in front of other 'servers' to get services that are available, so cues can form at the front or within the system."

For such systems to work well in health care, you need to couple cue management with cue discipline — or a way of prioritizing care services, explains Eitel. This can be done, for example, by putting an experienced clinician at the front of the ED so that he or she can quickly determine what care services patients need to access first.

"There are patients who need to be in a core ED bed because they are just sick, there are many patients who need diagnostic testing who don't need an ED bed, and there are also lots of patients who need some simple therapy, but not a core bed," says Eitel. "The way this works as a system is you put people into streams of care."

Align resources to meet demand

Underlying any effective system, there needs to be enough "innate service capacity" so that the ED does not become overwhelmed on a routine basis, explains Eitel, but he further stresses that constructing such a system in a department that is designed to handle emergencies is not as complicated as some would suggest. "Although there is tremendous variation [in volume] over the hours of the day, there is also tremendous predictability in the patterns of arrival," he says. "If Sunday afternoons are different than Tuesdays at midnight, then you align your resources and your services to meet demand."

It sounds straightforward enough, but Eitel says many EDs struggle with this task. Why? Because rather than having someone look at the big picture, they have physicians and nurses each doing their own staffing, registration will do its own staffing, and so on, explains Eitel. The result is that, at many EDs, there will be a waiting room full of patients and physicians in the ED with nothing to do because there is no "transporter" to take the patients upstairs.

"This happens all across the country. Physicians are sitting there and patients are in the waiting room because they haven't figured out what server type gets the bottleneck to flow," says Eitel. "You need to know what your demand is, in general, and then you can align capacity resources to meet the demand. That is a key principle, and it is not known by a lot of people."

Establish a patient-flow manager

High-volume EDs that pride themselves on efficiency and effective throughput might want to consider creating a position for a patient-flow manager, suggests Eitel. "This is a crackerjack nurse who is into system management and likes things to work," he says, comparing the position to the conductor of an orchestra. "You have to have your eye on a whole lot of players at all times to keep them all together, and the purpose is not to play music, but to keep people flowing through a specific system."

Ideally, the patient-flow manager will know the system so well that he or she will be able to make needed adjustments in resources when an unanticipated emergency or an influx of patients occurs. "Sometimes, you get two STEMIs [ST segment elevation myocardial infarction] in an hour. It changes a lot, so you borrow resources within the system from one pod to another and then put those resources back in their pods [when the patients have been cared for]," explains Eitel. "If you have someone who has a system, and knows the system, they have these scenarios in their heads ... so they can deploy their 'servers' around the needs that they have, and optimize flow in a prioritized way."

The example of the two STEMI cases is an apt illustration for why cue management and cue discipline need to take place throughout the ED process, not just on the front end, stresses Eitel. "All systems can be overwhelmed, but with dynamic management, you can recover quickly," he says. "Once you have a system described, and you have a system coordinator who gets it and is a good nurse, magic can happen."