- Email: [email protected]
ED Services: The Impact of Caring Behaviors on Patient Loyalty
RESEARCH
ED SERVICES: THE IMPACT OF CARING BEHAVIORS ON PATIENT LOYALTY Authors: Sandra S. Liu, PhD, David Franz, MHA, FACHE, Monette Allen, RN, MSN, En-Chung Chang, PhD (c), Dana Janowiak, MSHA, Patricia Mayne, RN, BSN, MHA, CEN, and Ruth White, RN, BSN, Lafayette, IN, St Louis, MO, Kokomo, IN, Birmingham, AL, and Detroit, MI
Earn Up to 9.5 CE Hours. See page 515. Introduction: This article describes an observational study of caring behaviors in the emergency departments of 4 Ascension Health hospitals and the impact of these behaviors on patient loyalty to the associated hospital. These hospitals were diverse in size and geography, representing 3 large urban community hospitals in metropolitan areas and 1 in a midsized city. Methods: Research assistants from Purdue University (West
Lafayette, IN) conducted observations at the first study site and validated survey instruments. The Purdue research assistants trained contracted observers at the subsequent study sites. The research assistants conducted observational studies of caregivers in the emergency departments at 4 study sites using convenience sampling of patients. Caring behaviors were rated from 0 (did not occur) to 5 (high intensity). The observation included additional information, for example, caregiver roles, timing, and type of visit. Observed and unobserved patients completed exit surveys that recorded patient responses to the likelihood-to-recommend (loyalty) questions, patient perceptions of care, and demographic information.
to an ED experience (prompt attention to their needs upon arrival to the emergency department); (2) the area that patients rated as least positive in their actual ED experience (prompt attention to their needs upon arrival to the emergency department); (3) caring behaviors that significantly affected patient loyalty (eg, making sure that the patient is aware of care-related details, working with a caring touch, and making the treatment procedure clearly understood by the patient); and (4) the impact of wait time to see a caregiver on patient loyalty. A number of correlations between caring behaviors and patient loyalty were statistically significant (P < .05) at all sites. Discussion: The study results raised considerations for ED
caregivers, particularly with regard to those caring behaviors that are most closely linked to patient loyalty but that occurred least frequently. The study showed through factor analysis that some caring behaviors tended to occur together, suggesting an underlying, unifying dimension to that factor.
Results: Common themes across all study sites emerged, including (1) the area that patients considered most important
Key words: Caring behaviors; Patient satisfaction; Patient
atient satisfaction is increasingly important in the health care sector. For example, the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospital Survey, also known as Hospital CAHPS, or HCAHPS, was developed by the Centers for Medicare & Medicaid Services and is a standardized instrument for measuring patients’ perspectives of hospital care.1 Voluntary data
P
collection using this instrument began in 2006, with the goal of providing data for consumers to compare hospitals in judging the patient experience of hospital care. Previous studies have shown that physician and nurse interpersonal interactions impact patients’ satisfaction and loyalty ratings. As physicians or nurses exhibit more caring behaviors including social connectedness,2 nonverbal expressions,3
Sandra S. Liu is Professor of Consumer Sciences and Retailing, Purdue University, West Lafayette, IN. David Franz is Manager, Ascension Health, St Louis, MO.
Ruth White, Member, Metro Birmingham Chapter, is Emergency Department Nurse Manager, St Vincent’s Birmingham, Birmingham, AL. For correspondence, write: David Franz, MHA, FACHE, 4600 Edmundson Rd, St. Louis, MO 63134; E-mail: [email protected].
Monette Allen is Manager of Emergency Services, St Joseph Hospital, Kokomo, IN. En-Chung Chang is PhD Candidate, Consumer Sciences and Retailing, Purdue University, West Lafayette, IN. Dana Janowiak is Business Manager, Medical Services, St Vincent’s Birmingham, Birmingham, AL. Patricia Mayne, Member, Huron Valley Chapter, is Administrative Director, Emergency Services, St John Hospital and Medical Center, Detroit, MI.
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loyalty
J Emerg Nurs 2010;36:404-14. Available online 23 February 2010. 0099-1767/$36.00 Copyright © 2010 by the Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. doi: 10.1016/j.jen.2009.05.001
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FIGURE 1 Ascension Health patient experience map. This patient experience map was developed through Ascension Health research, and the analysis shows the 6 most important attributes that comprise the patient experience. These attributes fall into 3 realms.
and verbal communication skills,4,5 patient satisfaction and/or likelihood-to-recommend scores increase. However, there is limited research on which specific caring behaviors are most important to a positive experience and patient loyalty. Ascension Health (St Louis, MO) determined that this relatively unstudied element of patient care was essential to providing a consistent, exceptional patient experience. Caring behaviors align with Ascension Health’s values, support its mission of providing holistic care, and contribute to improving patient loyalty, which is increasingly important to health care organizations operating in competitive markets. Caring behaviors have also been shown to improve quality of care. Studies of emotional care indicate that it fosters patients’ feelings of safety and reduces anxiety6 and enables rapport building and connection development between caregivers and patients,7 thereby benefiting long-term quality improvement and patient-caregiver relationships.8 The purpose of this study was to identify the impact of health care providers’ caring behaviors that lead to patient loyalty. Emergency departments were studied because (1) the length of stay and service structure of emergency departments are conducive to observational study and (2) emergency departments are a vital “front door” to most health care institutions, ser-
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ving a high volume of patients, many of whom are admitted as inpatients. Ascension Health completed extensive, unpublished research in June 2006 that included a survey of approximately 2,000 patients from 6 Ascension Health hospitals to define the experience desired by patients and their families. The results were used to develop a patient experience map that defined 6 attributes within 3 realms (Figure 1). In 2007 Ascension Health chose the Net Promoter Score (Satmetrix Systems, Inc., Bain & Company, Fred Reicheld) as the overarching metric to track Ascension Health’s success in delivering a positive patient experience (Figure 2). This loyalty metric, based on the familiar “likelihood-to-recommend” question, was chosen based on significant research that showed a correlation of this metric with market growth across other industries.9,10 Patient loyalty also is increasingly important to payers and a part of most surveys, including HCAHPS. On the Ascension Health experience map, realm 3 attributes are more highly correlated with the patient’s likelihood to recommend than realm 1 and 2 attributes. The realm 3 attributes included (1) compassionate, respectful care; (2) care responsiveness; and (3) communication and
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FIGURE 2 Calculating Net Promoter Score (NPS). The method for determining the NPS, based on the willingness-to-recommend question used in a number of industries, is shown. NPS is calculated by taking the percentage of promoters (individuals giving a rating of 9 or 10) and subtracting the percentage of detractors (individuals giving a rating of ≤6). Reprinted with permission from Bain & Co, Boston, MA.
empowerment. Thus this study of emergency departments focused on behaviors related to these 3 attributes. Methods
Study sites included a diverse mix of emergency departments in both size and geography and included the following: St Joseph Hospital in Kokomo, IN, a 167-bed community hospital with 23,000 annual visits to its emergency department; St John Hospital and Medical Center in Detroit, MI, a 658-bed urban teaching hospital with 98,000 annual visits to its level II trauma center; St Vincent’s Birmingham in Birmingham, AL, a 372-bed community/urban hospital with 42,000 annual visits to an emergency department that meets criteria for level III trauma; and Providence Hospital in Washington, DC, an urban hospital with 226 acute care beds and 47,000 annual ED visits. Each hospital’s institutional review board approved the study for its site. Funded by Ascension Health, researchers from the Department of Consumer Sciences and Retailing, Purdue University (West Lafayette, IN), designed the study and developed the study instruments based on literature review and consultation with medical professionals. The research team piloted the study at the emergency department of a 98-bed community hospital, validated the study instruments, and traveled to study sites to extensively train contracted observers using videos of role-playing on a range of patient-caregiver interaction situations. Inter-rater reliability was measured at 0.86 to 0.99 by use of correlation analysis, with inter-rater consistencies found to be satisfactory with reliabilities ranging from 0.86 to 0.99. The general process used at all sites is depicted in Figure 3, using convenience sampling of observation subjects. Patients at triage were assessed to determine whether they met criteria to be included in the study. Those patients who met the criteria were asked to participate and sign a consent form, which was cosigned by an emergency nurse to witness the consent.
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The patients were observed until discharge or for a minimum of 3 hours. The caregivers were not blinded to the study; each caregiver interacting with the observed patient was rated on a separate coding sheet, identified by caregiver category. At discharge, each patient was asked to complete an exit survey. The study also collected a targeted number of exit surveys completed by unobserved patients from 3 of the 4 sites to determine whether observation biased the findings. Unobserved patients were given an exit survey to determine whether observers impacted the perception of caring behaviors and overall loyalty ratings and to provide a more robust data set for rating unobserved dimensions of care. Two instruments were used to collect data for the study:
• The coding sheet was used by the research assistants to record the caring behaviors for each encounter. The scaling of behavior intensity ranged from 0 (did not occur) to 5 (high intensity). The coding sheet also included additional information such as caregiver roles, timing information, and type of visit (Appendix Figure 1). • The exit survey was completed by the patient at the end of the visit and was used for both observed and unobserved patients (Appendix Figure 2). It recorded (1) the likelihood-to-recommend (loyalty) questions, (2) the degree to which patients appreciated caring behaviors with their top 3 important areas ranked, and (3) demographic information.
The primary analysis of interest was a correlation analysis of observed behaviors and patient loyalty measured by use of 4 questions applied to the various caregiver categories. Other analyses included correlating observed behaviors with patient perceptions and time-stamp information to measure wait time for care. Time-stamp information was collected for observed patients including time from arrival to triage, from triage to see a registered nurse, and from triage to see a physician. These data were also correlated with patient loyalty. Patient and caregiver demographics were also studied. Factor analysis was applied to data at all sites to determine underlying behavior dimensions that impact patient loyalty. The following were key parameters of the study:
• The study was conducted at 4 emergency departments and included a total of 728 observed patients and 619 unobserved patients. Of the observed patients, there was a range of 150 to 200 observed at each site, with a minimum target of 150 per site. • The study was conducted from January to July 2007, with each site conducting a 3- to 4-month study within that time frame. • Patient demographics varied significantly by site, providing a rich and diverse data set for the study.
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FIGURE 3 General process for observed patients. The map shows the key steps involved in observing patients and the criteria used to determine whether to observe patients.
Results
The study findings provided meaningful information in a number of important areas relating to an emergency department’s ability to foster patient loyalty. Overall, the study findings indicated that caring behaviors do have an impact on patient loyalty, as evidenced by a number of statistically significant correlations (P < .05) (Table 1). The data showed strong statistical relationships between observed intensities or absence of caring behaviors and patient loyalty across a diverse sample (Table 2). Making sure the patient is aware of care-related details, working with a caring touch, and making the treatment procedure clearly understood by the patient showed the strongest correlations with patient loyalty. Furthermore, differences in patient loyalty scores and experience ratings between observed and unobserved patients were insignificant. A review of Press Ganey patient satisfaction surveys11 used at 3 of the 4 sites showed consistency with study findings; priority areas (priority index) based on correlation with overall satisfaction on the Press Ganey survey were consis-
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tent with many of the nurse and physician behaviors found to be significantly correlated in the study. A number of caring behaviors with significant correlations with loyalty across sites showed some common patterns, but there was significant variation among the 4 study sites in the caring behaviors by caregiver role that impacted loyalty. Though not the primary focus of the study, wait time to see caregivers had a significant impact on patient loyalty. It was reported as the most important area to patients yet was consistently ranked as the least positive area in their perceived experience. With regard to the caring behaviors that affected loyalty, there were differences based on patient gender but not based on patient race or age. At 2 sites, loyalty was correlated with information-based caring behaviors for male patients, whereas for female patients, loyalty was correlated with relationship-based caring behaviors. Although the impact on loyalty varied among sites, the pattern of the frequency of observed caring behaviors by caregiver role was consistent among study sites, with physicians exhibiting a greater number and intensity of caring behaviors than emergency nurses.
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TABLE 1
Correlation coefficients between caring behaviors and loyalty Caring behavior
Introduce himself or herself Show concern for family member’s needs and consideration Address family member’s questions patiently Positive facial expressions Chat with patient to help tune out illness state Respect patient’s privacy Make sure patient is aware of care-related detail before exiting Clearly communicate information to patient Explain to patient what to expect next Ask whether there is anything else that is needed before leaving Speak with a caring tone Explain purpose of visit Actively respond to patient’s need
Hospital site
Absent percentage of caring behavior
A, C A
−0.165 and −0.220 −0.321a
A, C A, C B B B, C
−0.385b and −0.451b
a
Intensity of caring behavior
b
0.195a and 0.155a −0.193
b
0.153a 0.157a and 0.273b
C C C
0.243b 0.214b 0.183a
C C C
0.179a 0.175a 0.160a
A, St. Joseph Hospital; B, St. Vincent's Birmingham; C, Providence Hospital. This table depicts correlations of caring behaviors and loyalty measured by the mean score of 2 measurements: “the likelihood of recommending the emergency department to your family and friends” and “the likelihood of recommending the hospital to your family and friends.” Caring behaviors for 1 site are not significantly correlated with the index of loyalty in the aggregate level. a P < .05. b P < .01.
Through factor analysis, 3 main factors emerged through the combined data set at all 4 sites. Certain caring behaviors within each of these factors tended to occur together, although there was no causal relationship among them. Nonetheless, there was an underlying dimension that unified the behaviors that occurred within a factor. The 3 factors and some of the associated behaviors were as follows:
• Care concern and communication, which included making sure the patient was aware of care-related details, proactively sharing health care knowledge, explaining what to expect next, making the treatment procedure clearly understood by the patient, and showing concern for non–treatment-related details, such as the patient’s family and job • Body language, which included facial expression, tone of voice, eye contact, active listening, respect for privacy, leaning toward the patient, and working with a caring touch • Initial greetings, which included caregivers introducing themselves and addressing the patient by name
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COMMON THEMES ACROSS ALL STUDY SITES
Despite variations in the study results, the following significant common themes emerged through descriptive, correlation, and factor analyses: 1. Areas rated as most important by patients, with regard to their ED experience • Patients at all 4 study sites rated prompt attention to needs upon arrival to the emergency department as most important. • Explaining the patient’s condition was ranked second in importance. • Depending on the study site, either making the patient feel comfortable or offering warm greetings ranked third in importance. 2. Areas patients rated least positive in their actual ED experience • There was consistency at all sites in what patients rated as least positive on their surveys: prompt attention to needs upon arrival to the emergency department. • Two areas—inquiring about patient fears and concerns and making the patient feel comfortable—accounted
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TABLE 2
Patient demographics Observed cases Unobserved cases (n = 728) (%) (n = 619) (%)
Gender Male 274 (37.6) Female 454 (62.4) Age <25 y 124 (17.0) 25-35 y 167 (22.9) 36-49 y 208 (28.6) 50-65 y 150 (20.6) >65 y 79 (10.9) Primary health insurance Medicare 128 (17.6) Medicaid 123 (16.9) Private insurance 369 (50.7) Self-pay 108 (14.8) Ethnicity White 289 (39.7) African American 387 (53.2) Hispanic 30 (4.1) Asian 4 (0.5) Other 18 (2.5)
242 (39.1) 377 (60.9) 109 123 198 129 60
(17.6) (19.9) (32.0) (20.8) (9.7)
104 (16.8) 123 (19.9) 320 (51.7) 72 (11.6) 147 (23.7) 439 (70.9) 21 (3.4) 2 (0.3) 10 (1.6)
for patients’ second and third least positive–rated areas, although the order varied site to site. 3. Caring behaviors with significant impact on patient loyalty • On the basis of the number of significant correlations at all sites between caring behaviors and patient loyalty, statistically significant behaviors emerged for all caregiver roles. Most of these behaviors were grouped in the same factor category of care concern and communication: • Make the treatment procedure clearly understood by the patient. Patients expected this behavior and responded with loyalty only when it was done well. If the behavior was absent, patient loyalty decreased. • Show concern for non–treatment-related details. This was an expected behavior, and if not present, loyalty decreased. • Make sure the patient is aware of care-related details, and explain what to expect next. These were 2 behaviors that significantly increased patient loyalty when they were performed well.
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4. Impact of wait time on patient loyalty • The area with the most significant gap in meeting patient expectations was wait time. This was based on patient-ranked areas of importance, the perceived experience, and the high correlation of wait time and patient loyalty. Although most emergency departments are aware of research that indicates the positive impact of reducing wait times on patient satisfaction,12,13 this study suggested that it is most important to reduce the time patients wait to see a physician or a primary emergency nurse after being triaged. • Time-stamp data also showed that wait time significantly impacted patient loyalty at all sites. Discussion
The findings of this study have implications for emergency departments:
• Supported patient experience research: These findings were consistent with other data linked to patient satisfaction. For example, the Press Ganey Emergency Department Pulse Report 2008 cited survey items “How well were you kept informed about delays” and “Degree to which staff cared about you as a person” as the number 1– and number 2–ranked priorities of patients that correlated to patient ratings of “likelihood of your recommending our emergency department to others.”14 • Created a framework of caring behaviors: Although the degree to which specific behaviors correlated with loyalty varied by site, factor analysis produced a distinct framework of the 3 factors referenced previously: care concern and communication, body language, and initial greetings. This framework can be used to develop and prioritize interventions, because certain caring behaviors tended to occur in the presence of other caring behaviors. Focusing on a specific factor and exploring ways to promote that factor may reveal additional caring behaviors that foster patient loyalty but that were not identified in the study. For example, a focus on care concern and communication could point to an underlying dimension of caregiver-patient dialogue. Exploring ways to enhance this dimension in the ED setting could lead to new caring behaviors that relate to the physical, emotional, and/or spiritual care of the patient. • Identified caring behaviors focus areas: Although the correlations between patient loyalty and specific caring behavior varied by site, a summary table of correlations for all sites showed several behaviors that had a high number of correlations with patient loyalty. Using these data in conjunction with an aggregate frequency
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FIGURE 4 Correlations to loyalty and frequency of occurrence. Depicted are 8 behaviors that highly correlate to loyalty, but they were not frequently exhibited during patient observations.
• • • • • • • •
of behavior occurrence for all sites showed potential areas of focus for all emergency departments (Figure 4). The study showed that the following behaviors had the highest number of correlations to patient loyalty combined with the lowest frequency of occurrence. The first 5 of these 8 behaviors fell under the factor category of care concern and communication. Because these 5 were among those behaviors most linked to loyalty, increasing their frequency could significantly improve patient loyalty scores. Make sure the patient is aware of care-related details. Explain to the patient what to expect next. Make the treatment procedure clearly understood by the patient. Chat with the patient to help tune out the illness state. Show concern for non–treatment-related details. Respect the patient’s privacy. Work with a caring touch. Make sure the family is aware of care-related details.
Limitations
As with many studies, a number of issues were identified that could strengthen future investigations of caring behaviors in the emergency department and their impact on patient loyalty: 1. Patients with a triage acuity level of 1 or 2 by use of the 5-level Emergency Severity Index were excluded from the study because of the difficulties in observing such
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patients, who typically require more intensive medical attention at a more accelerated pace. Ideally, a future study would include such patients to determine whether the same caring behaviors lead to patient loyalty among a population that is more acutely ill. 2. The observation periods were limited to the schedules of the research assistants, roughly 7 AM to 11 PM or midnight. At times, an observation was aborted because the patient visit outlasted the research assistant’s schedule. Thus a future study would benefit from 24-hour observation, both to ensure an accurate reflection of the entire 24-hour cycle of ED admissions and to ensure that observations that were begun could be brought to completion. 3. Although the study sites were diverse, not all populations/ regions were captured. A larger, more inclusive study would capture demographic subsets and determine whether the same caring behaviors lead to patient loyalty among these subsets. 4. The exit surveys of observed patients and unobserved patients were conducted at different times, largely because of logistics. Ideally, a future study would conduct both simultaneously. Implications for Emergency Nurses
Emergency departments planning to develop goals and strategies for improving the patient experience in the emergency department should consider these points: 1. Focus initially on those caring behaviors that were identified as correlating strongly with loyalty yet were not con-
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sistently displayed (Figure 4). The loyalty-linked behaviors that ED caregivers neglected offer the greatest potential for increasing patient loyalty. Designing efforts to concurrently address specific behaviors that are significantly correlated with loyalty and that fall within 1 of the 3 primary factors (care concern and communication, body language, and initial greetings) could lead to better understanding of the factor’s underlying dimension. 2. Develop and implement tactics to increase caregiver knowledge of caring behaviors and mechanisms to ensure their consistent delivery. • Use the ED study to build learning experiences. The measures used for this study could lead to an effective shadowing checklist when focusing on specific behaviors. For new recruits and in-service training, for example, caregivers could be paired during various patient encounters; a modified version of the observation tool used in this study could be developed for the shadowing experience. • Consider ways to more effectively communicate medical information in a proactive, timely, clear manner, especially during key patient-caregiver interactions. For example, St Vincent’s Birmingham established 30-minute targets for caregiver rounds for its ED patients. • Use the results of the ED study to better define staffing roles. Some examples are as follows: • Drawing on data from the ED study on the importance of patient communication and addressing family needs, St Joseph Hospital assessed staffing patterns to ensure that a staff member is present in the waiting area to communicate and interact with families in the triage area. • As a result of the ED study, St John Hospital and Medical Center tested a “care and comfort assistant” position for the purpose of attending to such needs. The first month of data after the implementation of the position showed a 12.2% increase in the “likelyto-recommend” question on the patient exit survey. 3. Implement strategies to decrease wait time to see a physician or primary emergency nurse. • Recognize the importance of patients seeing a physician or primary emergency nurse promptly. Consider adopting a time target for this initial introduction. As a result of this study finding, St Vincent’s Birmingham and St John Hospital and Medical Center each initiated a “door-to-doctor” time target of 30 and 32 minutes, respectively. 4. Set specific targets within patient satisfaction categories and monitor progress to measure effectiveness. • Develop an ED survey to assess the impact of interventions to increase the frequency of caring behaviors
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and to reduce wait time. St Vincent’s Birmingham created standards of behavior based on the ED study, conducted staff education about the behaviors, and developed and displayed posters in the emergency department that reinforced the behaviors. To measure the effectiveness of the program, a 5-question survey of ED patients was developed that addressed the standards of behavior. • Set goals to increase the mean score for specific areas and Net Promoter Score as an overall measure of patient loyalty.
Conclusion
This study revealed a correlation between caring behaviors shown by ED caregivers and subsequent patient loyalty, with new information emerging about this relationship. Some behaviors that were particularly important to patient loyalty were among those that occurred least frequently in the study, for example, chatting with patients to help tune out the illness state and showing concern for non–treatment-related details. Behaviors that were most closely linked to loyalty but occurred least frequently are logical targets for improvement. The factor category of care concern and communication showed the most potential because a number of its associated behaviors strongly correlated with patient loyalty but were not frequently exhibited during patient observations. In the study prompt attention to patients’ needs upon arrival to the emergency department not only emerged as most important to the patients’ ED experience but also proved to be the area patients rated as least positive in their actual ED experience. Time-stamp data also showed the link between wait time and patient loyalty. The study showed that the most important element of the wait time was between arrival at the emergency department and seeing a physician or primary emergency nurse. Providing personnel dedicated to care and comfort, creating standards of caring behavior and a corresponding patient survey, establishing time targets for caregiver rounds, and establishing wait time targets are examples of how to use the ED study results to improve patient loyalty.
REFERENCES 1.
HCAHPS Fact sheet. http://www.cms.hhs.gov/HospitalQualityInits/. September 2007. Accessed June 4, 2009.
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Hausman A. Modeling the patient-physician service encounter: Improving patient outcomes. J Acad Market Sci. 2004;32(4):403-17.
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Godkin J, Godkin L. Caring behaviors among nurses: Fostering a conversation of gestures. Health Care Manage Rev. 2004;29(3):258-67.
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Detmar SB, Muller MJ, Wever LD, et al. Patient-physician communication during outpatient palliative treatment visits: An observational study. JAMA. 2001;285(10):1351-7.
10. Reichheld F. The one number you need to grow. Harvard Business Review. December 1, 2003;81(12), 46-54.
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Otani K, Kurz RS. The impact of nursing care and other healthcare attributes on hospitalized patient satisfaction and behavior intentions. J Healthc Manag. 2004;49(3):181-96. Pålsson M-BE, Norberg A. Breast cancer patients’ experiences of nursing care with the focus on emotional support: The implementation of a nursing intervention. J Adv Nurs. 1995;21(2):277-85.
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Davies B, Oberle K. Dimensions of the supportive role of the nurse in palliative care. Oncol Nurs Forum. 1990;17(1):87-94.
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Skilbeck J, Payne S. Emotional support and the role of Clinical Nurse Specialists in palliative care. J Adv Nurs. 2003;43(5):521-30.
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Reichheld F. The Ultimate Question: Driving Good Profits and True Growth. Watertown, MA: Harvard Business School Press; 2006.
11. Press Ganey Partners in Improvement. http://www.pressganey.com/. Accessed July 1, 2008. 12. Kumar P, Kalwani M, Dada M. The impact of waiting time guarantees on customers’ waiting experiences. Mark Sci. 1997;16(4):295-314. 13. Indiana ranks in study of emergency room wait times. Inside Indiana business with Gerry Dick Web site. http://www.insideindianabusiness. com/newsitem.asp?ID=18352. Updated June 2, 2008. Accessed June 11, 2008. 14. Emergency department pulse report: Patient perspectives on American health care. Press Ganey. http://www.pressganey/com/galleries/defaultfile/2008_ED_Pulse_Report.pdf. Accessed June 9, 2009.
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APPENDIX FIGURE 1 Observer coding sheet.
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APPENDIX FIGURE 2 Patient exit survey.
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ED SERVICES: THE IMPACT OF CARING BEHAVIORS ON PATIENT LOYALTY Authors: Sandra S. Liu, PhD, David Franz, MHA, FACHE, Monette Allen, RN, MSN, En-Chung Chang, PhD (c), Dana Janowiak, MSHA, Patricia Mayne, RN, BSN, MHA, CEN, and Ruth White, RN, BSN, Lafayette, IN, St Louis, MO, Kokomo, IN, Birmingham, AL, and Detroit, MI
Earn Up to 9.5 CE Hours. See page 515. Introduction: This article describes an observational study of caring behaviors in the emergency departments of 4 Ascension Health hospitals and the impact of these behaviors on patient loyalty to the associated hospital. These hospitals were diverse in size and geography, representing 3 large urban community hospitals in metropolitan areas and 1 in a midsized city. Methods: Research assistants from Purdue University (West
Lafayette, IN) conducted observations at the first study site and validated survey instruments. The Purdue research assistants trained contracted observers at the subsequent study sites. The research assistants conducted observational studies of caregivers in the emergency departments at 4 study sites using convenience sampling of patients. Caring behaviors were rated from 0 (did not occur) to 5 (high intensity). The observation included additional information, for example, caregiver roles, timing, and type of visit. Observed and unobserved patients completed exit surveys that recorded patient responses to the likelihood-to-recommend (loyalty) questions, patient perceptions of care, and demographic information.
to an ED experience (prompt attention to their needs upon arrival to the emergency department); (2) the area that patients rated as least positive in their actual ED experience (prompt attention to their needs upon arrival to the emergency department); (3) caring behaviors that significantly affected patient loyalty (eg, making sure that the patient is aware of care-related details, working with a caring touch, and making the treatment procedure clearly understood by the patient); and (4) the impact of wait time to see a caregiver on patient loyalty. A number of correlations between caring behaviors and patient loyalty were statistically significant (P < .05) at all sites. Discussion: The study results raised considerations for ED
caregivers, particularly with regard to those caring behaviors that are most closely linked to patient loyalty but that occurred least frequently. The study showed through factor analysis that some caring behaviors tended to occur together, suggesting an underlying, unifying dimension to that factor.
Results: Common themes across all study sites emerged, including (1) the area that patients considered most important
Key words: Caring behaviors; Patient satisfaction; Patient
atient satisfaction is increasingly important in the health care sector. For example, the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospital Survey, also known as Hospital CAHPS, or HCAHPS, was developed by the Centers for Medicare & Medicaid Services and is a standardized instrument for measuring patients’ perspectives of hospital care.1 Voluntary data
P
collection using this instrument began in 2006, with the goal of providing data for consumers to compare hospitals in judging the patient experience of hospital care. Previous studies have shown that physician and nurse interpersonal interactions impact patients’ satisfaction and loyalty ratings. As physicians or nurses exhibit more caring behaviors including social connectedness,2 nonverbal expressions,3
Sandra S. Liu is Professor of Consumer Sciences and Retailing, Purdue University, West Lafayette, IN. David Franz is Manager, Ascension Health, St Louis, MO.
Ruth White, Member, Metro Birmingham Chapter, is Emergency Department Nurse Manager, St Vincent’s Birmingham, Birmingham, AL. For correspondence, write: David Franz, MHA, FACHE, 4600 Edmundson Rd, St. Louis, MO 63134; E-mail: [email protected].
Monette Allen is Manager of Emergency Services, St Joseph Hospital, Kokomo, IN. En-Chung Chang is PhD Candidate, Consumer Sciences and Retailing, Purdue University, West Lafayette, IN. Dana Janowiak is Business Manager, Medical Services, St Vincent’s Birmingham, Birmingham, AL. Patricia Mayne, Member, Huron Valley Chapter, is Administrative Director, Emergency Services, St John Hospital and Medical Center, Detroit, MI.
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J Emerg Nurs 2010;36:404-14. Available online 23 February 2010. 0099-1767/$36.00 Copyright © 2010 by the Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. doi: 10.1016/j.jen.2009.05.001
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FIGURE 1 Ascension Health patient experience map. This patient experience map was developed through Ascension Health research, and the analysis shows the 6 most important attributes that comprise the patient experience. These attributes fall into 3 realms.
and verbal communication skills,4,5 patient satisfaction and/or likelihood-to-recommend scores increase. However, there is limited research on which specific caring behaviors are most important to a positive experience and patient loyalty. Ascension Health (St Louis, MO) determined that this relatively unstudied element of patient care was essential to providing a consistent, exceptional patient experience. Caring behaviors align with Ascension Health’s values, support its mission of providing holistic care, and contribute to improving patient loyalty, which is increasingly important to health care organizations operating in competitive markets. Caring behaviors have also been shown to improve quality of care. Studies of emotional care indicate that it fosters patients’ feelings of safety and reduces anxiety6 and enables rapport building and connection development between caregivers and patients,7 thereby benefiting long-term quality improvement and patient-caregiver relationships.8 The purpose of this study was to identify the impact of health care providers’ caring behaviors that lead to patient loyalty. Emergency departments were studied because (1) the length of stay and service structure of emergency departments are conducive to observational study and (2) emergency departments are a vital “front door” to most health care institutions, ser-
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ving a high volume of patients, many of whom are admitted as inpatients. Ascension Health completed extensive, unpublished research in June 2006 that included a survey of approximately 2,000 patients from 6 Ascension Health hospitals to define the experience desired by patients and their families. The results were used to develop a patient experience map that defined 6 attributes within 3 realms (Figure 1). In 2007 Ascension Health chose the Net Promoter Score (Satmetrix Systems, Inc., Bain & Company, Fred Reicheld) as the overarching metric to track Ascension Health’s success in delivering a positive patient experience (Figure 2). This loyalty metric, based on the familiar “likelihood-to-recommend” question, was chosen based on significant research that showed a correlation of this metric with market growth across other industries.9,10 Patient loyalty also is increasingly important to payers and a part of most surveys, including HCAHPS. On the Ascension Health experience map, realm 3 attributes are more highly correlated with the patient’s likelihood to recommend than realm 1 and 2 attributes. The realm 3 attributes included (1) compassionate, respectful care; (2) care responsiveness; and (3) communication and
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FIGURE 2 Calculating Net Promoter Score (NPS). The method for determining the NPS, based on the willingness-to-recommend question used in a number of industries, is shown. NPS is calculated by taking the percentage of promoters (individuals giving a rating of 9 or 10) and subtracting the percentage of detractors (individuals giving a rating of ≤6). Reprinted with permission from Bain & Co, Boston, MA.
empowerment. Thus this study of emergency departments focused on behaviors related to these 3 attributes. Methods
Study sites included a diverse mix of emergency departments in both size and geography and included the following: St Joseph Hospital in Kokomo, IN, a 167-bed community hospital with 23,000 annual visits to its emergency department; St John Hospital and Medical Center in Detroit, MI, a 658-bed urban teaching hospital with 98,000 annual visits to its level II trauma center; St Vincent’s Birmingham in Birmingham, AL, a 372-bed community/urban hospital with 42,000 annual visits to an emergency department that meets criteria for level III trauma; and Providence Hospital in Washington, DC, an urban hospital with 226 acute care beds and 47,000 annual ED visits. Each hospital’s institutional review board approved the study for its site. Funded by Ascension Health, researchers from the Department of Consumer Sciences and Retailing, Purdue University (West Lafayette, IN), designed the study and developed the study instruments based on literature review and consultation with medical professionals. The research team piloted the study at the emergency department of a 98-bed community hospital, validated the study instruments, and traveled to study sites to extensively train contracted observers using videos of role-playing on a range of patient-caregiver interaction situations. Inter-rater reliability was measured at 0.86 to 0.99 by use of correlation analysis, with inter-rater consistencies found to be satisfactory with reliabilities ranging from 0.86 to 0.99. The general process used at all sites is depicted in Figure 3, using convenience sampling of observation subjects. Patients at triage were assessed to determine whether they met criteria to be included in the study. Those patients who met the criteria were asked to participate and sign a consent form, which was cosigned by an emergency nurse to witness the consent.
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The patients were observed until discharge or for a minimum of 3 hours. The caregivers were not blinded to the study; each caregiver interacting with the observed patient was rated on a separate coding sheet, identified by caregiver category. At discharge, each patient was asked to complete an exit survey. The study also collected a targeted number of exit surveys completed by unobserved patients from 3 of the 4 sites to determine whether observation biased the findings. Unobserved patients were given an exit survey to determine whether observers impacted the perception of caring behaviors and overall loyalty ratings and to provide a more robust data set for rating unobserved dimensions of care. Two instruments were used to collect data for the study:
• The coding sheet was used by the research assistants to record the caring behaviors for each encounter. The scaling of behavior intensity ranged from 0 (did not occur) to 5 (high intensity). The coding sheet also included additional information such as caregiver roles, timing information, and type of visit (Appendix Figure 1). • The exit survey was completed by the patient at the end of the visit and was used for both observed and unobserved patients (Appendix Figure 2). It recorded (1) the likelihood-to-recommend (loyalty) questions, (2) the degree to which patients appreciated caring behaviors with their top 3 important areas ranked, and (3) demographic information.
The primary analysis of interest was a correlation analysis of observed behaviors and patient loyalty measured by use of 4 questions applied to the various caregiver categories. Other analyses included correlating observed behaviors with patient perceptions and time-stamp information to measure wait time for care. Time-stamp information was collected for observed patients including time from arrival to triage, from triage to see a registered nurse, and from triage to see a physician. These data were also correlated with patient loyalty. Patient and caregiver demographics were also studied. Factor analysis was applied to data at all sites to determine underlying behavior dimensions that impact patient loyalty. The following were key parameters of the study:
• The study was conducted at 4 emergency departments and included a total of 728 observed patients and 619 unobserved patients. Of the observed patients, there was a range of 150 to 200 observed at each site, with a minimum target of 150 per site. • The study was conducted from January to July 2007, with each site conducting a 3- to 4-month study within that time frame. • Patient demographics varied significantly by site, providing a rich and diverse data set for the study.
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FIGURE 3 General process for observed patients. The map shows the key steps involved in observing patients and the criteria used to determine whether to observe patients.
Results
The study findings provided meaningful information in a number of important areas relating to an emergency department’s ability to foster patient loyalty. Overall, the study findings indicated that caring behaviors do have an impact on patient loyalty, as evidenced by a number of statistically significant correlations (P < .05) (Table 1). The data showed strong statistical relationships between observed intensities or absence of caring behaviors and patient loyalty across a diverse sample (Table 2). Making sure the patient is aware of care-related details, working with a caring touch, and making the treatment procedure clearly understood by the patient showed the strongest correlations with patient loyalty. Furthermore, differences in patient loyalty scores and experience ratings between observed and unobserved patients were insignificant. A review of Press Ganey patient satisfaction surveys11 used at 3 of the 4 sites showed consistency with study findings; priority areas (priority index) based on correlation with overall satisfaction on the Press Ganey survey were consis-
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tent with many of the nurse and physician behaviors found to be significantly correlated in the study. A number of caring behaviors with significant correlations with loyalty across sites showed some common patterns, but there was significant variation among the 4 study sites in the caring behaviors by caregiver role that impacted loyalty. Though not the primary focus of the study, wait time to see caregivers had a significant impact on patient loyalty. It was reported as the most important area to patients yet was consistently ranked as the least positive area in their perceived experience. With regard to the caring behaviors that affected loyalty, there were differences based on patient gender but not based on patient race or age. At 2 sites, loyalty was correlated with information-based caring behaviors for male patients, whereas for female patients, loyalty was correlated with relationship-based caring behaviors. Although the impact on loyalty varied among sites, the pattern of the frequency of observed caring behaviors by caregiver role was consistent among study sites, with physicians exhibiting a greater number and intensity of caring behaviors than emergency nurses.
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TABLE 1
Correlation coefficients between caring behaviors and loyalty Caring behavior
Introduce himself or herself Show concern for family member’s needs and consideration Address family member’s questions patiently Positive facial expressions Chat with patient to help tune out illness state Respect patient’s privacy Make sure patient is aware of care-related detail before exiting Clearly communicate information to patient Explain to patient what to expect next Ask whether there is anything else that is needed before leaving Speak with a caring tone Explain purpose of visit Actively respond to patient’s need
Hospital site
Absent percentage of caring behavior
A, C A
−0.165 and −0.220 −0.321a
A, C A, C B B B, C
−0.385b and −0.451b
a
Intensity of caring behavior
b
0.195a and 0.155a −0.193
b
0.153a 0.157a and 0.273b
C C C
0.243b 0.214b 0.183a
C C C
0.179a 0.175a 0.160a
A, St. Joseph Hospital; B, St. Vincent's Birmingham; C, Providence Hospital. This table depicts correlations of caring behaviors and loyalty measured by the mean score of 2 measurements: “the likelihood of recommending the emergency department to your family and friends” and “the likelihood of recommending the hospital to your family and friends.” Caring behaviors for 1 site are not significantly correlated with the index of loyalty in the aggregate level. a P < .05. b P < .01.
Through factor analysis, 3 main factors emerged through the combined data set at all 4 sites. Certain caring behaviors within each of these factors tended to occur together, although there was no causal relationship among them. Nonetheless, there was an underlying dimension that unified the behaviors that occurred within a factor. The 3 factors and some of the associated behaviors were as follows:
• Care concern and communication, which included making sure the patient was aware of care-related details, proactively sharing health care knowledge, explaining what to expect next, making the treatment procedure clearly understood by the patient, and showing concern for non–treatment-related details, such as the patient’s family and job • Body language, which included facial expression, tone of voice, eye contact, active listening, respect for privacy, leaning toward the patient, and working with a caring touch • Initial greetings, which included caregivers introducing themselves and addressing the patient by name
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COMMON THEMES ACROSS ALL STUDY SITES
Despite variations in the study results, the following significant common themes emerged through descriptive, correlation, and factor analyses: 1. Areas rated as most important by patients, with regard to their ED experience • Patients at all 4 study sites rated prompt attention to needs upon arrival to the emergency department as most important. • Explaining the patient’s condition was ranked second in importance. • Depending on the study site, either making the patient feel comfortable or offering warm greetings ranked third in importance. 2. Areas patients rated least positive in their actual ED experience • There was consistency at all sites in what patients rated as least positive on their surveys: prompt attention to needs upon arrival to the emergency department. • Two areas—inquiring about patient fears and concerns and making the patient feel comfortable—accounted
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TABLE 2
Patient demographics Observed cases Unobserved cases (n = 728) (%) (n = 619) (%)
Gender Male 274 (37.6) Female 454 (62.4) Age <25 y 124 (17.0) 25-35 y 167 (22.9) 36-49 y 208 (28.6) 50-65 y 150 (20.6) >65 y 79 (10.9) Primary health insurance Medicare 128 (17.6) Medicaid 123 (16.9) Private insurance 369 (50.7) Self-pay 108 (14.8) Ethnicity White 289 (39.7) African American 387 (53.2) Hispanic 30 (4.1) Asian 4 (0.5) Other 18 (2.5)
242 (39.1) 377 (60.9) 109 123 198 129 60
(17.6) (19.9) (32.0) (20.8) (9.7)
104 (16.8) 123 (19.9) 320 (51.7) 72 (11.6) 147 (23.7) 439 (70.9) 21 (3.4) 2 (0.3) 10 (1.6)
for patients’ second and third least positive–rated areas, although the order varied site to site. 3. Caring behaviors with significant impact on patient loyalty • On the basis of the number of significant correlations at all sites between caring behaviors and patient loyalty, statistically significant behaviors emerged for all caregiver roles. Most of these behaviors were grouped in the same factor category of care concern and communication: • Make the treatment procedure clearly understood by the patient. Patients expected this behavior and responded with loyalty only when it was done well. If the behavior was absent, patient loyalty decreased. • Show concern for non–treatment-related details. This was an expected behavior, and if not present, loyalty decreased. • Make sure the patient is aware of care-related details, and explain what to expect next. These were 2 behaviors that significantly increased patient loyalty when they were performed well.
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4. Impact of wait time on patient loyalty • The area with the most significant gap in meeting patient expectations was wait time. This was based on patient-ranked areas of importance, the perceived experience, and the high correlation of wait time and patient loyalty. Although most emergency departments are aware of research that indicates the positive impact of reducing wait times on patient satisfaction,12,13 this study suggested that it is most important to reduce the time patients wait to see a physician or a primary emergency nurse after being triaged. • Time-stamp data also showed that wait time significantly impacted patient loyalty at all sites. Discussion
The findings of this study have implications for emergency departments:
• Supported patient experience research: These findings were consistent with other data linked to patient satisfaction. For example, the Press Ganey Emergency Department Pulse Report 2008 cited survey items “How well were you kept informed about delays” and “Degree to which staff cared about you as a person” as the number 1– and number 2–ranked priorities of patients that correlated to patient ratings of “likelihood of your recommending our emergency department to others.”14 • Created a framework of caring behaviors: Although the degree to which specific behaviors correlated with loyalty varied by site, factor analysis produced a distinct framework of the 3 factors referenced previously: care concern and communication, body language, and initial greetings. This framework can be used to develop and prioritize interventions, because certain caring behaviors tended to occur in the presence of other caring behaviors. Focusing on a specific factor and exploring ways to promote that factor may reveal additional caring behaviors that foster patient loyalty but that were not identified in the study. For example, a focus on care concern and communication could point to an underlying dimension of caregiver-patient dialogue. Exploring ways to enhance this dimension in the ED setting could lead to new caring behaviors that relate to the physical, emotional, and/or spiritual care of the patient. • Identified caring behaviors focus areas: Although the correlations between patient loyalty and specific caring behavior varied by site, a summary table of correlations for all sites showed several behaviors that had a high number of correlations with patient loyalty. Using these data in conjunction with an aggregate frequency
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FIGURE 4 Correlations to loyalty and frequency of occurrence. Depicted are 8 behaviors that highly correlate to loyalty, but they were not frequently exhibited during patient observations.
• • • • • • • •
of behavior occurrence for all sites showed potential areas of focus for all emergency departments (Figure 4). The study showed that the following behaviors had the highest number of correlations to patient loyalty combined with the lowest frequency of occurrence. The first 5 of these 8 behaviors fell under the factor category of care concern and communication. Because these 5 were among those behaviors most linked to loyalty, increasing their frequency could significantly improve patient loyalty scores. Make sure the patient is aware of care-related details. Explain to the patient what to expect next. Make the treatment procedure clearly understood by the patient. Chat with the patient to help tune out the illness state. Show concern for non–treatment-related details. Respect the patient’s privacy. Work with a caring touch. Make sure the family is aware of care-related details.
Limitations
As with many studies, a number of issues were identified that could strengthen future investigations of caring behaviors in the emergency department and their impact on patient loyalty: 1. Patients with a triage acuity level of 1 or 2 by use of the 5-level Emergency Severity Index were excluded from the study because of the difficulties in observing such
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patients, who typically require more intensive medical attention at a more accelerated pace. Ideally, a future study would include such patients to determine whether the same caring behaviors lead to patient loyalty among a population that is more acutely ill. 2. The observation periods were limited to the schedules of the research assistants, roughly 7 AM to 11 PM or midnight. At times, an observation was aborted because the patient visit outlasted the research assistant’s schedule. Thus a future study would benefit from 24-hour observation, both to ensure an accurate reflection of the entire 24-hour cycle of ED admissions and to ensure that observations that were begun could be brought to completion. 3. Although the study sites were diverse, not all populations/ regions were captured. A larger, more inclusive study would capture demographic subsets and determine whether the same caring behaviors lead to patient loyalty among these subsets. 4. The exit surveys of observed patients and unobserved patients were conducted at different times, largely because of logistics. Ideally, a future study would conduct both simultaneously. Implications for Emergency Nurses
Emergency departments planning to develop goals and strategies for improving the patient experience in the emergency department should consider these points: 1. Focus initially on those caring behaviors that were identified as correlating strongly with loyalty yet were not con-
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sistently displayed (Figure 4). The loyalty-linked behaviors that ED caregivers neglected offer the greatest potential for increasing patient loyalty. Designing efforts to concurrently address specific behaviors that are significantly correlated with loyalty and that fall within 1 of the 3 primary factors (care concern and communication, body language, and initial greetings) could lead to better understanding of the factor’s underlying dimension. 2. Develop and implement tactics to increase caregiver knowledge of caring behaviors and mechanisms to ensure their consistent delivery. • Use the ED study to build learning experiences. The measures used for this study could lead to an effective shadowing checklist when focusing on specific behaviors. For new recruits and in-service training, for example, caregivers could be paired during various patient encounters; a modified version of the observation tool used in this study could be developed for the shadowing experience. • Consider ways to more effectively communicate medical information in a proactive, timely, clear manner, especially during key patient-caregiver interactions. For example, St Vincent’s Birmingham established 30-minute targets for caregiver rounds for its ED patients. • Use the results of the ED study to better define staffing roles. Some examples are as follows: • Drawing on data from the ED study on the importance of patient communication and addressing family needs, St Joseph Hospital assessed staffing patterns to ensure that a staff member is present in the waiting area to communicate and interact with families in the triage area. • As a result of the ED study, St John Hospital and Medical Center tested a “care and comfort assistant” position for the purpose of attending to such needs. The first month of data after the implementation of the position showed a 12.2% increase in the “likelyto-recommend” question on the patient exit survey. 3. Implement strategies to decrease wait time to see a physician or primary emergency nurse. • Recognize the importance of patients seeing a physician or primary emergency nurse promptly. Consider adopting a time target for this initial introduction. As a result of this study finding, St Vincent’s Birmingham and St John Hospital and Medical Center each initiated a “door-to-doctor” time target of 30 and 32 minutes, respectively. 4. Set specific targets within patient satisfaction categories and monitor progress to measure effectiveness. • Develop an ED survey to assess the impact of interventions to increase the frequency of caring behaviors
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and to reduce wait time. St Vincent’s Birmingham created standards of behavior based on the ED study, conducted staff education about the behaviors, and developed and displayed posters in the emergency department that reinforced the behaviors. To measure the effectiveness of the program, a 5-question survey of ED patients was developed that addressed the standards of behavior. • Set goals to increase the mean score for specific areas and Net Promoter Score as an overall measure of patient loyalty.
Conclusion
This study revealed a correlation between caring behaviors shown by ED caregivers and subsequent patient loyalty, with new information emerging about this relationship. Some behaviors that were particularly important to patient loyalty were among those that occurred least frequently in the study, for example, chatting with patients to help tune out the illness state and showing concern for non–treatment-related details. Behaviors that were most closely linked to loyalty but occurred least frequently are logical targets for improvement. The factor category of care concern and communication showed the most potential because a number of its associated behaviors strongly correlated with patient loyalty but were not frequently exhibited during patient observations. In the study prompt attention to patients’ needs upon arrival to the emergency department not only emerged as most important to the patients’ ED experience but also proved to be the area patients rated as least positive in their actual ED experience. Time-stamp data also showed the link between wait time and patient loyalty. The study showed that the most important element of the wait time was between arrival at the emergency department and seeing a physician or primary emergency nurse. Providing personnel dedicated to care and comfort, creating standards of caring behavior and a corresponding patient survey, establishing time targets for caregiver rounds, and establishing wait time targets are examples of how to use the ED study results to improve patient loyalty.
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Reichheld F. The Ultimate Question: Driving Good Profits and True Growth. Watertown, MA: Harvard Business School Press; 2006.
11. Press Ganey Partners in Improvement. http://www.pressganey.com/. Accessed July 1, 2008. 12. Kumar P, Kalwani M, Dada M. The impact of waiting time guarantees on customers’ waiting experiences. Mark Sci. 1997;16(4):295-314. 13. Indiana ranks in study of emergency room wait times. Inside Indiana business with Gerry Dick Web site. http://www.insideindianabusiness. com/newsitem.asp?ID=18352. Updated June 2, 2008. Accessed June 11, 2008. 14. Emergency department pulse report: Patient perspectives on American health care. Press Ganey. http://www.pressganey/com/galleries/defaultfile/2008_ED_Pulse_Report.pdf. Accessed June 9, 2009.
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APPENDIX FIGURE 1 Observer coding sheet.
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APPENDIX FIGURE 2 Patient exit survey.
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