BRIEF REPORT
patient satisfaction
EmergencyDepartment Satisfaction: What
Matters Most?
From the Departments of Brenda Bursch, PhD* Study objective: To determine the relative importance of vari-
Organization Effectiveness* Joseph Beezy, MD t ables correlated with patient satisfaction with emergency
and EmeTgency Medicine,t Ruth Shaw, RNt
Kaiser Permanente Medical Care department care and service.
Program, Southern California
Regon, Los Angeles, California.
Design: Retrospective telephone survey targeting all patients
who visited the Panorama City Kaiser Permanente ED from
Receivedfor publication
August 3i, 1992. Accepted for April 4 to April 17, 1991. Patients were contacted within one
publication September 21, 1992. week of their discharge from the ED or hospital.
Participants: Two hundred fifty-eight ED patients completed
telephone surveys. Fifty-one percent of the respondents were
male, and the mean age was 53 years. The majority of the
respondents were white (70%}; the most common service
received was medical (82%).
Measurements and results: Of the 14 variables that were
found to be correlated with overall ED satisfaction, a multiple
regression analysis revealed that the five most important vari-
ables were patient satisfaction with the amount of time it took
before being cared for in the ED; patients' ratings of how caring
the nurses were, how organized the ED staff was, and how car-
ing the physicians were; and patient satisfaction with the
amount of information the nurses gave them about what was
happening to them.
Conclusion: The total time patients spend in the ED and
patients' perceptions of their wait time for an ED bed are not as
important to patient satisfaction as is receiving prompt and car-
ing service. The above service variables are key areas that may
be targeted to improve ED services.
[Bursch B, Beezy J, Shaw R: Emergencydepartment satisfaction:
What matters most? Ann EmergMed March 1993;22:586-591.]
9 2 / 58 6 ANNALS OF EMERGENCY MEDICINE 22:3 MARCH i993
SATISFACTION
Bursch, Beezy & Shaw
INTHODUCTION The purpose of this study was to determine the relative
As consumerism and public awareness of health services importance of several components of patient satisfaction
grow, the health care industry has become more concerned with ED service. The specific satisfaction dimensions
with evaluating patient satisfaction with care. Satisfaction examined were art of care and wait time because these
with ambulatory care in particular has been shown to dimensions are the most amenable to short-term change
have significant influence on patient adherence with treat- efforts. Results were used to plan efforts to increase
ment plans and return to the care setting. 1 The weight of patient satisfaction.
published evidence regarding the characteristics of
providers and medical care services that influence patient MATERIALS AND METHODS
satisfaction favors the use of satisfaction as an outcome Setting The Kaiser Permanente Medical Care Program is a
measure in evaluating health and medical services. 2 group practice prepayment plan providing comprehensive
Dimensions that have been used in the study of patient medical and hospital services to members enrolled in 12
satisfaction include art of care, quality of care, regions across the United States. Each region is federally
convenience, finances, physical environment, availability, qualified as a health maintenance organization. The
continuity of care, and outcomes of care. 2 Panorama City Medical Area is one of ten medical areas
Although much is understood about patient satisfac- included in the Southern California region. The Panorama
tion with general medical services, there are few studies City ED is located within a 331-bed hospital. Patients
measuring patient satisfaction with emergency services. who present for immediate care are triaged either to the
The research that has been conducted suggests that lower-acuity medical and surgical urgent care areas or to
important satisfaction dimensions for emergency depart- the ED. The ED is responsible for high-acuity patients
ment patients include art of care, quality of care, wait time, who arrive by ambulance or through nurse triage or are
and billing. 3-s Although it is important to understand sent by physicians in other parts of the medical center for
which aspects of the ED are related to satisfaction, under- emergency care or admission to the hospital.
standing their relative importance is critical to strategically Questionnaire Construction A telephone interview ques-
plan improvements that will most efficiently increase tionnaire composed of both forced choice and open-
)atient satisfaction. ended questions was designed to measure components of
patient satisfaction with wait time, the nurses, the physi-
Figure. cians, and the ED in general (patient perception questions
Patient perception questions
presented in the Figure). In addition, patient demographic
information (age, sex, ethnic group, and length of health
1. About how long did you have to wait before you were brought into a
room and put to bed? plan membership) and medical information (acuity, diag-
2. About how long did you have to wait in the examination room before nosis, services received, and disposition) were included.
someone started to give you medica/ care?
3. Overall, how satisfied or dissatisfied are you with the amount of time it
took before you were cared for in the emergency department?
4. Did the medical staff introduce themselves to you when they first came Table 1,
into your room? Reasons i n t e ~ i e w s were not completed
5. Flow satisfied or dissatisfied are you with the amount of information the
nurses gave you about what was happening to you?
6. Did you have someone with you when you came into the emergency
Reason No. of Patients
department?
If yes: Did the nurses keep them informed of your condition? Wrong or disconnected telephone number 58
If no: Did the nurses offer to help you contact someone to let them Answering machine reached 20
know where you were? No answer 20
7. Overall, how caring or uncaring were the nurses? Moved 6
8. How satisfied or dissatisfied are you with the amount of information the On vacation 4
physicians gave you about what was happening to you? Not home 7
9. Overall, how caring or uncaring were the doctors? Refused 8
10. How organized or unorganizedwas the emergency department staff? Did not speak English or Spanish 2
11. When you were in the emergency department, did you know how to get Deceased 2
help if you needed it? Does not remember ED 7
12. Were you given instructions about how to care for yourself after you Hard of hearing 3
were sent home?
Too ill to answer 21
13. Overall, how satisfied are you with the care you received in the
Still in or back in hospital 17
emergency department?
Total 175
MARCH 1993 22:3 ANNALS OF EMERGENCY MEDICINE 5 8 7/ 9 3
SATISFACTION
Bursch, Beezy & Shaw
As Kaiser Permanente is a prepaid health care plan, issues Statistical Analyses Statistical analyses were performed
related to billing were not included in the questionnaire. using the Statistical Package for the Social Sciences
Study Design and Administration A list was obtained of (SPSSx). Prequencies were used to describe the respon-
all patients who presented to the ED from April 4 to dents' demographic and medical characteristics. Pearson
April 17, 1991. Patients were telephoned and asked correlations were conducted to examine the relationships
whether they would be willing to participate in a ten-minute among the variables. A multiple regression, using the for-
interview about their recent visit to the ED. Those who ward selection procedure, was performed to determine
agreed were interviewed at that dme or at a time they which variables would statistically predict overall satisfac-
considered more convenient. If the patient was less than tion with care received.
18 years old, the parent who accompanied the child to the
ED was asked to answer the questions. RESULTS
Reliability and quality of the data collected were
A total of 433 ED patients were called, and 258 (59%)
ensured by conducting an intensive training session with
completed interviews. Of the interviews, 97.3% (249)
all interviewers. Each interviewer received a procedures
were conducted in English, and 2.7% (seven) were in
manual and verbal explanation of each questionnaire item
Spanish. When an interviewer did not reach the patient
and then took part in role-playing during the training
on the telephone, repeated attempts were made at differ-
workshop. All telephone interviewers were under super-
ent times of the day. Some interviews were not completed
vision and were monitored randomly to ensure uniform
(Table 1).
interviewing procedures.
Table 2. Table 3.
Demographic characteristics of patients Medical characteristics of patients
Respondents Respondents
Characteristic No. % Characteristic No. %
Age (yr) Acuity*
0 to 9 5 1.9 1-Very low 12 4.7
10to 19 15 5.8 2-Low 70 27.;
20 to 29 19 7.4 3-Medium 163 59.3
30 to 39 35 13.6 4-High 23 8.9
40 to 49 28 10.9 5-Ven/high 0 0.0
50 to 59 35 13.6 Diagnosis
60 to 69 53 20.5 Psychiatric 4 1.7
70 to 79 49 19.0 Heart problems 60 25.9
80 to 89 19 7.4 Respiratory problems 8 3.4
Sex Other acute medical 109 47.0
Male 131 51.0 Other chronic medical 21 9.1
Female 126 49.0 Trauma 11 4.7
Ethnic Group Other 19 8.2
Native American 3 1.2 Services Receivedt
Asian 5 2.0 Psychiatric 5 1.9
8lack 20 7.8 Surgery 5 1.9
Filipino 5 2.0 Medical 21I 81.8
Hispanic 41 162 Obstetrics 11 4.3
White 177 69.7 Special procedure 22 8.5
Other 3 1.2 Trauma 4 1,6
Length of Kaiser Permanente Disposition
Health Plan Membership (yr) Home 137 53.3
1 to 5 60 25.0 Admit 118 45.9
6 to 10 33 13.7 Transfer 1 0.4
11 to 15 24 10.0 Discharged against medical advice 1 0.4
16 to 20 51 21.3 N = 258; actualnumberof patientson which percentagesare basedmayvaryslightlyfor each
21 to 43 72 30.6 variablebecausemedica/datawere not availablefor everypatient.
N = 258; actualnumberef patientsan which percentagesare basedmayvaryslightlyfor each *Determinedin the EDby presenceand durationof signsand symptoms.
variablebecausenot everyquestionwas answeredby everypatient. tCatagoriesusedby EDfor staffing purposes.
9 4/ 5 8 8 ANNALS OF EMERGENCYMEDICINE 22:3 MARCH 1993
SATISFACTION
Burs&, Boozy & Shaw
Information is presented about the demographic and To determine the relative importance of variables that
medical characteristics of the sample of patients who correlated with patient satisfaction with ED services, a
participated in the telephone interview (Tables 2 and 3). multiple regression was performed using the forward
Of the 258 ED patients who completed telephone surveys, selection procedure. The significant statistical predictors
51% were male, the mean age was 53 years, the majority of overall ED satisfaction were satisfaction with the
were white (69.7%), and the most common service amount of time it took before being cared for in the ED;
received was medical (81.8%). patients' ratings of how caring the nurses were, how
Pearson correlations were conducted to determine organized the ED staff was, and how caring the physicians
which variables are related to overall satisfaction with ED were; and satisfaction with the amount of information the
services. The 13 items that correlated positively with over- nurses gave them about what was happening to them
all satisfaction were health plan member's age, years as a (Table 5).
health plan member, perceptions that the ED staff was
organized, the ED staff introducing themselves, knowing DISCUSSION
how to get help while in a hospital bed, being given self-
Although published research suggests that art of care,
care instructions on discharge, perceptions that the nurses
quality of care, billing, and wait time are important satis-
were caring, receiving information from nurses about
faction dimensions for ED patients, their relative impor-
what was happening, family being informed about the
tance has been unclear. Our study allowed a more careful
patient's condition, receiving help in contacting a relative,
analysis of the satisfaction dimensions of art of care and
perceptions that the physicians were caring, receiving
wait time as they relate to each other and as they relate to
information from physicians about what was happening,
overall satisfaction with the ED.
and satisfaction with the amount of time it took before
Although recommendations have been made in the
receiving care (Table 4)~ Negatively correlated with overall
literature to increase staffing in order to reduce wait time
satisfaction was the amount of time that members
and increase patient satisfaction, 9 our results suggest that
perceived they waited in their beds to receive care.
reducing actual time spent in the ED may not be sufficient
to increase patient satisfaction. The most important vari-
able associated with overall satisfaction with ED services
Table 4. was satisfaction with the amount of time it took before the
Service variables related to overall satisfaction with care received
patient was cared for in the ED. As this was a more impor-
tant variable than the total time patients actually spent in
Variable Pearson Correlation the ED or patients' perceptions of the length of time they
Demographic Variables waited for an ED bed, it appears that the important con-
Age .20* cept is being "cared for" in a timely manner rather than
Years as member .14t
Medical Variable simply being processed quickly through the ED. This
Acuity .09 conclusion is further supported by the result that caring
Provider Variables nurses was the next most important variable and caring
Organized ED staff .63"
Staff introducing self ,45* physicians was the fourth most important variable associ-
Knowing howto get help .47* ated with overall satisfaction.
Given instructions on discharge .56*
Nurses
Caring nurses .64" Table 5.
Information from nurses .68*
Multiple regression summary table of overall satisfaction with care
Informed family about condition .44*
Help in contacting relative .42*
received
Physicians
Caring physicians .64*
Step Variable 6 MultipleR Rz F P
Information from physicians .63*
Waiting times 1 Satisfaction with
Satisfaction with time waited for care .66" wait forcare .71 ,71 .50 170.66 <.001
Actual time spent in ED -.10 2 Caring nurses .43 .79 .63 140.35 <.001
Perception of wait time for bed .03 3 Organized staff .26 .82 .67 113.41 < .001
Perception of wait time for care -.29* 4 Caring doctors .21 .83 .70 94.99 < .001
*P< .01. 5 Satisfaction with
~P< .05. information from nurses .16 .84 .71 80.15 <.001
MARCH 1993 22:3 ANNALS OF EMERGENCY MEDICINE 5 8 9/ 9 5
SATISFACTION
Bursch, Beezy & 5haw
In addition to stressing the importance of maintaining that ED satisfaction is re]ated to satisfaction with wait
a caring attitude, suggestions about how to provide caring time, the causal direction of the relationship was not
service in a timely manner may be gleaned from the litera- determined. Because patient satisfaction has previously
ture and from the other two variables that we found to be been found to be influenced by various dimensions of
particularly important to overall ED satisfaction. Our find- care received, the results have been discussed within this
ing that it is important for patients to receive information framework.
from the nurses about what is happening to them is There are several research directions that may offer
supported by a study conducted by Bjorvell and Stieg, an opportunity to understand ED satisfaction more
who found increased satisfaction among patients who thoroughly Although our study examined the satisfaction
were given information on arrival to the ED about what dimensions of art of care and wait time because they are
would happen to them next. 3 more amenable to change efforts, issues regarding quality
In addition to informing patients about what is happen- of care and billing have been demonstrated in other
ing to them and what will happen next, an intervention studies to also be important components of ED satisfaction.
suggested by Gagnon is to educate patients about the ser- Patient satisfaction dimensions that have been studied in
vices they are receiving. ~o Combining this suggestion with other settings also would contribute to the literature on
research findings, one would expect patient satisfaction to ED satisfaction; these dimensions include accessibility/
increase if a nurse were to inform the patient that they are convenience, physical environment, continuity, and
initiating care, perform a cursory examination, record efficacy/outcomes of care. Finally, although this study
medical information for the physician, and/or inform the suggests that satisfaction would increase with early
patient of their place in the queue before a physician could nursing intervention, early physician intervention may be
be expected to see them. These interventions would attend the key to increased patient satisfaction. Future research
to the importance of having an organized ED staff and may that identifies variables such as who first cares for the
increase patient satisfaction among patients who previous- patient, what tasks are performed by the initial caregiver,
ly viewed their care as beginning when the physician and how long the patient waited before the caregiver
arrived. Furthermore, these interventions may be began care would help to clarify what patients mean
performed in the waiting room if ED beds are not readily when they say they want immediate and caring service.
available. Although such service requires an investment of
nursing time, this is time saved for the physician and less CONCLUSION
costly than an increase in physician staffing. The most important variables associated with overall satis-
Limitations of this study included issues of generaliz- faction with ED services were satisfaction with the amount
ability As Kaiser Permanente is a group practice prepaid of time it took before the patient was cared for in the ED;
health plan, patients' service expectations may differ from patients' ratings of how caring the nurses were, how
those of patients who enroll in other health plan models. orgamzed the ED staff was, and how caring the physidans
Also, patients at the Panorama City Medical Center who were; and satisfaction with the amount of information the
require prompt care are triaged to the urgent care walk-in nurses gave them about what was happening to them. The
departments or to the ED. Consequently, the patients total time patients actually spent in the ED and patients'
included in this study were more acutely ill than those perceptions of the length of time they waited for an ED
who are found in most EDs. Satisfaction with wait time bed were found to be less important than receiving some
may be more important to the study patients than it is to immediate attention and caring service.
patients who are less acutely ill. Finally, no information Patient satisfaction may be increased among those
was obtained to allow the statistical comparison of patients who have traditionally considered the physician~
respondents and nonrespondents to determine if there arrival as the initiation of treatment if a nurse were to
are meaningful differences between the two groups that inform the patient that they are initiating care, perform a
would bias the sample. It is known that the respondents cursory examination, record medical information for the
reflect the medical and demographic profile of the popula- physician, and/or inform the patient of their queue before
tion that uses this ED. a physician could be expected to see them. These inter-
Finally, this study was limited by the research design, ventions may'be performed in the waiting room if ED
which allowed the examination of variables related to beds are not available and are less costly than the frequent
satisfaction but did not allow conclusions of causation to suggestion of increasing physician staffing.
be drawn. For example, while it is clear from our study
£ B / 5g 0 ANNALS OF EMERGENCY MEDICINE 22:3 MARCH 1993
SATISFACTION
Bursch, Beezy & Shaw
REFERENCES The authors thank Panorama City Medical Center; David Potyk, MD, Area Associate
Medical Director. Department of Organization Effectiveness; and Lenore
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