Improving patients’ experience in the emergency department by changing staff perceptions of their roles

The paper was published in the European Journal of Emergency Medicine.

Principal investigator Leo Kobayashi, M.D., an emergency medicine physician at Rhode Island Hospital, and his colleagues developed a study to determine how emergency department (ED) personnel's perceived job responsibilities impact the patient experience. They developed an online survey to query the staff on their perceptions of select clinical care-related actions that can affect a patient's level of satisfaction when receiving urgent care.

Kobayashi explains, "Emergency department patients are frequently anxious and frightened, sometimes confused and often in pain. Providing patients with care that consistently and effectively addresses their emotions and needs, thereby leaving them satisfied with their visit, remains a challenge in busy and stressful ED settings." He continues, "We know about some factors that impact patient satisfaction, but to date, what has not been fully explored is the clinical staff's insight into personal responsibilities and their perceptions of individual roles in creating a positive experience for the patient."

By surveying a cross-sectional representation of staff from the ED, the researchers proposed that an online survey could identify discipline- or service-dependent demarcations in ownership of a select list of important patient clinical care activities, such as communicating with patients and their families. Kobayashi says, "Understanding who actively takes responsibilities for the key actions that are expected to contribute to a positive patient experience would enable 'mapping' of staff members' perceived domains of individual responsibility. Such mapping could then reveal 'dead zones' that fall outside of perceived staff duties, thereby identifying target areas for improvement."

The researchers designed an online survey to first obtain information about perceived roles in three primary categories -- communication and rapport, direct clinical care and disposition/follow-up. The survey also included examples of the different types of activities that would support improved patient satisfaction, and asked if the subjects would change, consider change, or not change their current performance and behavior. As Kobayashi explains, "This allowed us to include an embedded intervention in the survey that would suggest reasonable actions that our staff could consider and subsequently perform in order to improve the patient experience." These self-reported anticipated changes in future job performance were recorded as secondary outcome measurements by the researchers.

With 153 subjects responding (117 primary ED care providers and 36 support staff), the researchers were able to obtain 3047 responses to 3802 queries as to whether subjects believed a specific activity was considered within their provider role, such as "providing for the patient's general physical comfort."

Kobayashi reports that of the active ED personnel surveyed, most subjects generally considered the majority of clinical care activities presented to be part of their individual clinical duties, with moderate exceptions for those related to patient disposition and follow-up. Primary ED care providers reported greater ownership of surveyed activities. He says, "Of interest, a substantial proportion of support staff expressed responsibility for various actions taking place over the entire clinical care spectrum. These findings support the notion of a shared and collaborative approach to patient care."

In terms of the intervention goal, Kobayashi notes, "Although the intervention was limited, a significant number of providers expressed an intent or consideration of changing their clinical activities in direct response to the suggested behaviors."

He concludes, "This survey was very helpful in identifying gaps in our ED clinical care so that we can help improve our patients' satisfaction; ongoing research is likely to be fruitful for a deeper understanding of perceptions of roles within the ED."

Kobayashi's principal affiliation is Rhode Island Hospital, a member hospital of the Lifespan health system in Rhode Island. Direct financial and infrastructure support for this project was received through the Lifespan Office of Research Administration. Kobayashi also holds an academic appointment at The Warren Alpert Medical School of Brown University. The material in the study is based on work supported by the University Emergency Medicine Foundation (www.uemf.org) and the department of emergency medicine at Rhode Island Hospital. The study subject incentives were funded through a research grant from the department of emergency medicine at Alpert Medical School.

Other researchers involved in the study with Kobayashi include Lynn Sweeney, M.D., Anna Cousins, B.A., Karina Bertsch, M.S.W., Fenwick Gardiner, B.S., Nicole Tomaselli, B.S., Robert Boss, R.N., Frantz Gibbs, M.D., and Gregory Jay, M.D., M.P.H., all of Rhode Island Hospital and Alpert Medical School.