In 2014, the emergency department (ED) at a community hospital in Southern California decided to develop real-time processes to handle service failures. The goal was to uncover issues such as lengthy waits, unhelpful staff, messy rooms, etc., which could be acknowledged before the patient left the hospital.
Providing an optimal patient experience is the right thing to do for patients. But it’s also important for a number of other reasons:
- The Centers for Medicare & Medicaid Services now ties reimbursement to Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores.
- Patient experience in the hospital overall often mirrors the experience they have in the ED, so it’s important to start a patient’s journey on the right foot.
- Patient satisfaction surveys are useful but don’t allow a hospital to address service problems in a timely manner.
The role of the ED in patient experience
There’s another important reason to focus on the patient experience at the ED level: Previous research from the Mayo Clinic shows that when patients who have a less-than-optimal experience recover, their satisfaction transcends the level of loyalty of a patient who had an initial positive experience.
At many hospitals today, 65% to 70% of admissions come from the ED. Often patients admitted through the ED score much lower on HCAHPS surveys in all domains versus those electively admitted to the hospital. Improved and sustained HCAHPS performance remains a high priority that places the patient experience squarely in the crosshairs of every CEO.
With this information, and with the goal of improving the overall patient experience, our hospital ED team created an inpatient rounding program.
Knocking on doors
Despite believing in the value to be gained, we launched the program with some trepidation. This wasn’t the hospital’s first experience with inpatient rounding. About a year earlier, administrators had asked ED nurse managers and directors to visit patients on the units. However, there were no significant gains in patient satisfaction or HCAHPS scores with that program.
Upon analysis, we determined one reason for the lack of improvement was because managers didn’t feel a sense ownership or pride in doing task-oriented rounding. What’s more, the program lacked clear goals and identifiable next steps to address problems.
Still, we felt there was a need to explore this approach further. Rather than spend months building a program that would require committee review, after informing administration of our plan and receiving their approval, we just started knocking on the doors of patients the day after they were admitted to the ED.
Our outreach was informal and simple in its design, initially consisting of one ED physician and nurse manager. We simply asked them about their experience in the ED: what went well and what could have been better. We discovered that inpatient rounding doesn’t take a lot of time, but taking a few minutes to connect with patients authentically makes a world of difference to them, and provides valuable information to us as providers.
The emotional response we received from patients was overwhelming. We had patients cry from gratitude that someone cared enough to check on them the next day. One woman ran into her ED physician’s arms when we came in to visit her husband. He had just received a terminal diagnosis and was going into hospice, so knowing we cared meant a lot to her.
As ED providers, we rarely experience that level of patient connection or feedback. Traditionally, we take care of the patient in the ED in times of crisis and chaos. We are there with them through some tense times, stabilize them and then handle admission or discharge. Despite the intensive nature of the interaction, most ED physicians rarely see those patients after that initial care.
However, with inpatient rounding, we have the opportunity to let patients know we’re still thinking about them and can ask them how we could have improved their experience. Patients have an opportunity to provide immediate feedback. Plus, they see a truly integrated team caring for them. When patients experience teamwork, they feel safe. And partnering with patients and their families in validating their issues or concerns is a powerful way to gain trust, promote loyalty and improve satisfaction as well as their experience.
Starting a revival
Once we had established a system for inpatient rounding, which included a feedback loop of patient and family comments, we encouraged other ED providers to join in. Although the concept was initially met with reluctance by a few partners (“I’m too busy” was the most common response), physicians began coming in a half-hour before their shifts to round on patients. And once they began participating in inpatient rounding, they too became more engaged and began to see the benefits.
Our colleagues quickly realized that the vast majority of comments from patients and family members are positive. Nobody in this environment gets enough positive reinforcement, and ED physicians and nurses quickly recognized the benefit of starting their shift on a positive note.
That’s not to say that we don’t receive complaints. Positive or negative, we share the feedback we receive about the noise level, cleanliness, communication, and other issues with the ED nurses and other staff during our morning and evening shift huddles.
Of the complaints we receive, about 15% are unrecoverable; we won’t be able to address those patients’ problems for a variety of reasons. Perhaps it is something out of our control, or a personality conflict, or some other issue. But that still gives us 85% of problems we can address.
Most patients who have a complaint simply want to know that someone took the time to listen, own the problem and not make excuses. A powerful phrase to communicate ownership of the issue(s) and engage the patient/family while helping to diffuse a potentially adversarial situation is:
“I can understand your frustration(s). This might not be my fault, but it’s my problem. Thank you for taking the time to bring this to my attention.”
The timing of service failure identification is important because it’s much more meaningful and effective to address a complaint while the patient is still in the hospital than deal with it on the backend, when you receive a letter or phone call a week or two later. Since we started inpatient rounding, the number of service issues has decreased significantly. We realized we had a revival going on.
Breaking down silos
When inpatient nursing units saw how engaged ED physicians and nurses were in caring for patients throughout their entire hospital stay, they soon became part of the process. The entire hospital saw the momentum of positivity and energy that resulted from the ED’s inpatient rounding project.
The ED nurses and physicians were seen as leaders and role models in the patient experience. We became known as the team to call upon when there was a difficult situation with a patient.
Breaking down silos in the hospital was not an explicit objective of our inpatient rounding program. But looking back, it was clearly one of the most powerful influences in eliminating barriers between departments and increasing engagement throughout the hospital.
A little empathy goes a long way
By the time we complete residency, ED physicians in particular often have the empathy burned out of us. Nearly everything we do is task- and process-oriented, which is important in delivering excellent clinical care. But when we lose perspective and the ability to connect with a patient because we’re focused on the tasks we need to perform and the 10 patients waiting to be seen, we’re sacrificing that patient’s experience at that time.
Instituting inpatient rounding to improve the patient experience is good for ED providers, for patients and for the organization. It’s about implementing culture change through leading by example and sustaining the momentum by a shared data feedback mechanism. It’s about getting out of your comfort zone and genuinely engaging patients and families in ways that encourage openness about their experience and using that information to build a better patient experience—the kind of experience you’d want for yourself and your family members.
Edward Pillar, DO, FACEP, is the director of quality and performance for CEP America, a physician-owned multi-specialty partnership serving more than 6.3 million patients annually, and providing clinical staffing, management and consulting services for more than 250 hospitals, skilled nursing facilities and other practice sites throughout the United States.
Editor's note: this piece has been updated to correct the information describing CEP America.