Patient satisfaction depends on staff morale

ED manager who scores high shares tips

If you want to improve your ED’s patient satisfaction ratings, don’t start by looking at how happy your patients are. Start by looking at satisfaction levels among your staff. That’s the advice from an ED manager who can boast of patient satisfaction scores in the 99th percentile nationwide.

The ED at Hackettstown (NJ) Community Hospital has earned high patient satisfaction levels in recent years, which can be directly tied to improvements resulting in better employee morale and customer service, says Loraine Skeahan, RN, manager of the ED.

"The lesson may be that if you want to improve patient satisfaction, go deeper than that and address the fundamentals in the emergency department like how well you’re staffed and how happy your staff are," Skeahan says.

If you start off by going to patients and asking how to make them happy, you might be wasting your time, she says. "Chances are, they don’t really know what could be improved in your department to make their visit better," Skeahan says.

In a recent patient satisfaction survey conducted by The Jackson Organization, a health care research organization based in Columbia, MD, Hackettstown’s ED patients gave the hospital an overall satisfaction grade of 4.27 (on a 5 point scale, where 1 is poor and 5 is excellent). This compared to an overall 3.97 grade for competing hospitals serving the area and gave Hackettstown a 99th percentile ranking among hospital EDs nationwide.

Expanded ED helped patient satisfaction

In its research, The Jackson Organization identified several key predictors of Emergency Patient Satisfaction. Hackettstown’s ED scored especially well in three areas:

1. Staff Availability to Provide Assistance at all Times.

2. How Well the Hospital Did at Meeting its Mission.

3. Total Amount of Time Spent in the Facility from Arrival to Discharge or Hospital Admission.

The Hackettstown ED also ranked exceptionally well in four other key areas:

1. How Quickly Nurses Responded to Requests.

2. Kindness Shown by the Nurses.

3. Kindness Shown by the Doctor.

4. How Well the Staff Kept the Patient and Family Informed about the Patient’s Care and Condition.

Part of the high satisfaction ranking can be related to physical improvements in the ED, Skeahan says. The hospital recently completely rebuilt its emergency area with 13 rooms, more than double the previous six rooms. The number of ED staff were doubled, and the number of secretarial support staff were increased to speed up paperwork and data entry.

"By streamlining waiting times and increasing space and staff, we reduced the average length of stay in the emergency department to less than an hour for those who were treated and released," Skeahan says.

Doubling its size was an absolute need, she says. "The population in Northwest Jersey is growing, and we went from 30 visits a day to 60 or 70 a day," Skeahan says.

The ED staff now make a priority of getting the patient triaged, evaluated, and to a physician as quickly as possible. Physicians now provide double coverage on high-volume days.

Peg Carolan, RN, the hospital’s director of nursing and its former ED administrator, says she worked hard to create a better working atmosphere for the ED nurses, which in turn helped them provide better care to patients.

Nearly everyone in the ED, including lab and X-ray technicians, support staff, and nurses, went through a program called Spirit of Caregiving, offered by Lant & Associates in Winter Park, FL, which helped them bond as teammates and learn to work toward a larger goal of improved patient care. That kind of effort paid off over time with better morale, she says. 

"Now, when a nurse calls in sick, those who are here either volunteer to take that nurse’s place or else find a substitute," she says. "The keys to our success are the ability of our staff to create a warm and caring environment and patient-focused team, as we strive to achieve our mission of reflecting God’s love in healing each patient’s body, mind, and spirit."

Though the effort worked wonders for Hackettstown, bigger EDs with more challenges may have more trouble creating such a family atmosphere for staff.

That doesn’t mean you shouldn’t try, says Marilyn Swinford, director of emergency services at Saint Joseph Hospital, a 446-bed hospital in Lexington, KY. Her ED recently won the second place award for Overall Emergency Department Satisfaction for Large Hospitals given by The Jackson Organization.

Swinford says her ED’s high patient satisfaction ratings came from some of the same morale-building initiatives used in Hackettstown, such as a new "Star of the Month" program to recognize efforts that improve patient satisfaction. But the Kentucky ED’s overcrowding meant it also had to implement some specific strategies aimed at getting patients through the ED faster.

First, Swinford organized a focus group with triage and registration that helped trim registration times to an average of fewer than five minutes. Saint Joseph also put much more effort into keeping patients informed about expected wait times.

While EDs focus so much on reducing wait times, they too often overlook the importance of keeping patients informed, she says. Patients will be much more willing to wait, and ultimately express satisfaction with their visits, if they know how long they will wait and that there is a good reason for the delay.

"Customers want to know what to expect so proactive communicating is critical," Swinford says. "We are improving in informing patients reasons for wait times, focusing on keeping them informed of the overall expectation of what is happening related to their ED visit and what to expect."

Point-of-care laboratory testing also has shortened door-to-diagnosis times. Testing processes to provide chemistry and cardiac screening were implemented in January 2003. Swinford says these devices have shortened the average test time from 90 minutes to 20 minutes — a huge change for anxious and impatient patients.

She also credits focused teamwork between the ED and cath lab, along with bedside treatment "AMI boxes" that have critical IV access and medications for cardiac emergencies, for providing smoother patient flow.

Listen to staff and give them what they need

When trying to improve staff morale as a way to improve patient satisfaction, Carolan and Swinford emphasize that you must listen to your frontline employees and remember that improvements don’t happen overnight.

"Our success took several years to accomplish," Carolan says.

ED managers should pay particular attention to fully staffing the ED and providing support services to clinicians, Skeahan says. She offers this advice for improvements that can lead to high patient satisfaction scores:

Provide ancillary support staff.

Nurses and other staff can be frustrated by having to do everything, including tasks that don’t require their expertise. The Hackettstown ED operated for years without any ancillary or secretarial support, but Carolan added an ED tech position a few years ago. Now an ED tech works in the ED every night and every other weekend. The tech acts as an extra pair of hands wherever needed to assist with tasks such as performing a phlebotomy, transporting patients, and obtaining vital signs.

"This position works side by side with the nurse, rather than replacing a nurse," Skeahan says. "It’s not the same as hiring another nurse, because that nurse would become busy with everything else and couldn’t jump in wherever they’re needed."

Provide secretarial support.

Hackettstown now has two secretaries in the ED during the day and one in the evening. This removes a great deal of the paperwork burden from the nursing staff, Skeahan says.

Take educational opportunities to the ED.

Staff usually are interested in learning, but ED staff can find it difficult to get out of the department for inservices. If they don’t attend, they feel left out. If you don’t offer any inservices because you think they’re too busy, they may miss the opportunity to learn more about the field. The solution is to take the inservices to the ED, Skeahan says.

"When you have some downtime, go to the unit and start a troubleshooting session or discuss the latest topics like pediatrics in the ED," she says. "They really love it because they want to learn, but you have to be very flexible with inservices in this department."


For more information, contact:

Loraine Skeahan, RN, ED Manager, Hackettstown Community Hospital, 651 Willow Grove St., Hackettstown, NJ 07840. Telephone: (908) 852-5100.

Peg Carolan, RN, Director of Nursing, Hackettstown Community Hospital, 651 Willow Grove St., Hackettstown, NJ 07840. Telephone: (908) 852-5100.

Marilyn Swinford, Director of Emergency Services, Saint Joseph Hospital, One Saint Joseph Drive, Lexington, KY 40504. Telephone: (859) 313-1000.

The Spirit of Caregiving program is offered by Lant & Associates, 1555 Howell Branch Road, No. C202, Winter Park, FL 33179. Telephone: (407) 740-8098. E-mail: Web:

[Editor’s note: This column is part of an ongoing series that addresses reader questions about the Emergency Medical Treatment and Active Labor Act (EMTALA). If you have a question you’d like answered, contact Greg Freeman, Editor, ED Management, 3185 Bywater Trail, Roswell, GA 30075. Telephone: (770) 998-8455. E-mail:]