The entire staff of Duke University Hospital's Emergency Department, plus affiliated staff, banded together to improve patient satisfaction scores by focusing on improving service. That effort led to a significant increase, from the 30th percentile to the 75th.

On first glance, the Duke University Hospital Emergency Department has nothing at all in common with a Ritz Carlton.

In the waiting room sit patients who are, more often than not, suffering from physical discomfort and anxious about getting help. Emotions can run high and waits can be long.

However, within the past year, new renovations coupled with a sea of changes in staff attitudes toward service has led to significant increases in the level of patient satisfaction.

“Your hard work and dedication to quality improvement is evident in the increase in your Emergency Room Service score Overall Satisfaction,” read a letter from Press Ganey, the patient satisfaction reporting and consulting company used by the Health System.

“Our new attitude echoes the Ritz Carlton motto: ‘Ladies and gentleman serving ladies and gentleman’,” said Michael Hocker, MD, chief of the division of Emergency Medicine. Our new service excellence motto is professionals caring for our community and together we make it happen.

That simple shift in attitude, from one that focused primarily on health care delivery and not service, along with a number of procedural changes, has led to tangible rewards in a relatively short period of time.

“Our scores were consistently in the 25th to 30th percentile. Feedback from patients indicated that our staff members were not communicating and that we didn’t care,” said Hocker. The latest results from Press Ganey: the ED hit the 75th percentile.

The key behind the changes has been teamwork of the ED staff, from the front-desk receptionist to the nurses to the attending physicians and administrators. As a unit, they brainstormed ways to improve how business was done in an increasingly busy emergency department. The department now serves between 190 to 220 patients a day.

First, Hocker traveled with clinical operations director Frank DeMarco, patient visitor relations representative Matthew Rougeux and other ED staff members to Hackensack, New Jersey to visit a highly-rated emergency department to see what they were doing differently. They brought some of those tips back to Duke and, with those guidelines, the division got to work.

Better Communication, Happier Patients

“We set up a committee of nurses, physicians and administrators to devise ways to respond to common patient concerns,” said Candi Van Vleet, RN, nurse manager of operations.

They began to realize that a consistent theme was not the level of care, but communication, or the lack thereof.

“Before, patients’ perceptions were that that staff members had an attitude, were short with them or weren’t forthcoming with information,” said Matt Rougeux, patient advocate. Rougeux handles patient concerns within the ED.

Patients waiting to be seen for long periods of time often felt as if they were forgotten. One of the most successful initiatives has been the installation of “Nurse First,” in which a nurse is stationed at the reception area to triage patients upon arrival. That nurse can begin basic lab work until there is room for a patient on the unit. Waiting patients are also reassessed every two hours.

“Patients tell me that this step makes them feel like someone is paying attention to their needs,” said Theresa Davis, RN.

The staff report that Nurse First has also led to improved patient flow. “Before we started this, we were rarely able to empty the waiting room and now that occurs regularly,” said Bill Lyons, RN.

Once inside the unit, patients are now more informed about who is caring for them and what their treatment course consists of thanks to two other initiatives.

The first, bedside reporting, has nurses and assistants updating each other at shift changes at a patient’s bedside, so that the patient can listen and give feedback. The second is a white board on the wall of each room, listing the date, the name of the patient’s nurse, attending physician, the plan for the day, and space for questions or comments.

“Our communication is much more patient-centered. We’ve made a conscious attempt to keep them in the loop so that they feel more in control of their treatment,” said Van Vleet.

Administrators, such as the charge nurse, physician team leaders, and representatives from ancillary services such as food service and radiology, are now more actively involved as well, performing rounds to ensure, in real time, that patients are getting the care they deserve.

And that care continues even after a patient has been discharged. Within 48 hours, leadership staff and attending physicians will now call patients to touch base.

“Physicians will ask how they are doing and ask about their service. The follow-up calls have provided an additional element of safety, allowing physicians to clarify treatment instructions if needed,” said DeMarco.

Finally, real-time surveys have empowered staff to be proactive about patient concerns. Each patient is given a form with 10 questions about their treatment, while they are still on the unit. If they score below a certain number, the charge nurse checks in with them to see what can be improved.

“Getting positive feedback in real time has resulted in our feeling better about the job we’re doing,” said Casey Baughman, RN.

As one patient wrote: “The entire staff from triage to the resident and attending physicians was superb. The bedside manner of the physicians was absolutely wonderful.  My nurse was very kind, as well as the lady taking my insurance information.”

All of this change hasn’t been easy. “There has been a lot of trial and error in the process, with some improvements working well and others not at all. But we’ve remained flexible and the administration has done a great job at being receptive and open to our suggestions,” said Lyons.

“This is an amazing accomplishment,” said Kevin Sowers, CEO of DUH. “It’s the staff that have really driven this process. It was a team effort that led to rapid cycle improvement.”

Baughman summed up the staff’s new attitude this way: “It’s now the universal goal of the unit to recognize patients as human beings with needs and wants, not just medical conditions, and to respond accordingly. Whatever we can do to improve their experience while they are here is worth it.”