Framework for analyzing wait times and other factors that impact patient satisfaction in the emergency department.

BACKGROUND: Wait times and patient satisfaction are important administrative metrics in emergency departments (EDs), as they are critical to return patronage, liability, and remuneration. Although several factors have been shown to impact patient satisfaction, little attention has been paid to understanding the psychology of waiting and patient satisfaction. OBJECTIVE: We utilize concepts that have been applied in other service industries to conceptualize factors that impact patient satisfaction. We focus on wait times, a key factor in patient satisfaction, and describe how these concepts can be applied in research and daily practice. DISCUSSION: Patient satisfaction can be conceptualized as the difference between a patient's perceptions and their expectations. Perception is the psychological process by which an individual understands and interprets sensory information. Changes in the wait experience can decrease the perceived wait times without a change in actual wait times. Other changes such as improved staff interpersonal and communication skills that provide patients with an increased sense of the staff's dedication as well as a greater understanding of their care, can also affect patient perceptions of their care quality. These changes in patient perception can synergize with more expensive investments such as state-of-the-art facilities and increased ED beds to magnify their impact on patient satisfaction. Expectation is the level of service a patient believes they will receive during their ED visit. Patients arrive with expectations around the component of their care such as wait times, needed diagnostic tests, and overall time in the ED. These expectations are affected by individual-specific, pre-encounter, and intra-encounter factors. When these factors are identified and understood, they can be managed during the care process to improve patient satisfaction. CONCLUSION: Interventions to decrease perception of wait times and increase the perception of service being provided, when combined with management of patient expectations, can improve patient satisfaction

Help Us Help You: Engaging Emergency Physicians to Identify Organizational Strategies to Reduce Burnout

Introduction: Burnout is a major threat to patient care quality and physician career longevity in emergency medicine. We sought to develop and implement a quality improvement process to engage emergency department (ED) faculty in identifying sources of burnout and generating interventions targeted at improving the work environment.Methods: In this prospective interventional study conducted at a large, urban, academic medical center, we surveyed a 60-person faculty group using the Professional Fulfilment Index (PFI), as well as burnout-relevant questions from the American Medical Association’s Mini-Z survey and the Maslach-Leiter framework for organizational burnout, in order to identify organizational sources of burnout. We assessed the relationship between burnout scores and responses to the Maslach-Leiter framework using univariate regression analysis. In a two-hour facilitated session, we shared survey results and led the group in a process using the six Maslach-Leiter domains to develop a rank-ordered list of interventions to reduce burnout in each domain.Results: In total, 47 of 60 faculty (78.3%) completed the survey and 45 faculty (75%) attended the discussion session. Of the 47 survey respondents, 14 (30%) met criteria for moderate to severe burnout. The respondents’ answers to the Maslach-Leiter organizational burnout domain questions were significantly correlated with their burnout scores (P <0.001). Session attendees generated 31 potential interventions for process improvement, which were analyzed and thematically organized. Common intervention themes included reducing documentation burden, receiving more positive feedback on patient care, improving ease of obtaining consults, decreasing ED crowding, and increasing intrafaculty social connection. Interventions were subsequently reviewed and scored based on relative importance and feasibility to create a departmental action plan for process improvement.Conclusion: Using the Maslach-Leiter organizational burnout framework, in conjunction with a facilitated solution-oriented faculty discussion, led to the creation of a departmental agenda focused on organizational solutions for augmenting professional fulfillment and reducing burnout. We propose that this process can be used by healthcare organizations to engage physicians and others in efforts to improve their work experiences, which in turn is likely also to support the provision of higher quality of care

Types and Timing of Teaching During Clinical Shifts in an Academic Emergency Department

Objectives: Academic emergency physicians must find ways to teach residents, medical students, and advanced practice providers amidst the myriad demands on their time during clinical shifts. In this study, we sought to characterize in detail what types of teaching occurred, how often they occurred, and how attending teaching styles differed at one academic emergency department (ED).Methods: We conducted this observational study in a large, urban, quaternary care, academic Level I trauma center with an emergency medicine (EM) residency. The on-shift activities of EM attending physicians (attendings) were observed and recorded over 42 hours by a fourth-year EM resident with co-observations by an EM education fellow. Teaching categories were identified, developed iteratively, and validated by the study team. We then characterized the distribution of teaching activities during shifts through the coding of attending activities every 30 seconds during observations. Teaching archetypes were then developed through the synthesis of notes taken during observations.Results: Attendings spent a mean of 25% (standard deviation 7%) of their time engaging in teaching activities during shifts. Of this teaching time 36% consisted of explicit instruction, while the remaining 64% of teaching occurred implicitly through the discussion of cases with learners. The time distribution of on-shift activities varied greatly between attendings, but three archetypes emerged for how attendings coupled patient care and teaching: “in-series”; “in-parallel modeling”; and “in-parallel supervision.”Conclusions: Teaching in this academic ED took many forms, most of which arose organically from patient care. The majority of on-shift teaching occurred through implicit means, rather than explicit instruction. Attendings also spent their time in markedly different ways and embodied distinct teaching archetypes. The impact of this variability on both educational and patient care outcomes warrants further study

Types and Timing of Teaching During Clinical Shifts in an Academic Emergency Department

Objectives: Academic emergency physicians must find ways to teach residents, medical students, and advanced practice providers amidst the myriad demands on their time during clinical shifts. In this study, we sought to characterize in detail what types of teaching occurred, how often they occurred, and how attending teaching styles differed at one academic emergency department (ED).Methods: We conducted this observational study in a large, urban, quaternary care, academic Level I trauma center with an emergency medicine (EM) residency. The on-shift activities of EM attending physicians (attendings) were observed and recorded over 42 hours by a fourth-year EM resident with co-observations by an EM education fellow. Teaching categories were identified, developed iteratively, and validated by the study team. We then characterized the distribution of teaching activities during shifts through the coding of attending activities every 30 seconds during observations. Teaching archetypes were then developed through the synthesis of notes taken during observations.Results: Attendings spent a mean of 25% (standard deviation 7%) of their time engaging in teaching activities during shifts. Of this teaching time 36% consisted of explicit instruction, while the remaining 64% of teaching occurred implicitly through the discussion of cases with learners. The time distribution of on-shift activities varied greatly between attendings, but three archetypes emerged for how attendings coupled patient care and teaching: “in-series”; “in-parallel modeling”; and “in-parallel supervision.”Conclusions: Teaching in this academic ED took many forms, most of which arose organically from patient care. The majority of on-shift teaching occurred through implicit means, rather than explicit instruction. Attendings also spent their time in markedly different ways and embodied distinct teaching archetypes. The impact of this variability on both educational and patient care outcomes warrants further study

Documentation Displaces Teaching in an Academic Emergency Department

Introduction: Adverse effects of administrative burden on emergency physicians have been described previously, but the impact of electronic health record documentation by academic emergency attendings on resident education is not known. In this observational study of a quaternary care, academic emergency department, we sought to assess whether the amount of time attending physicians spent on documentation affected the amount of time they spent teaching.Methods: A fourth-year emergency medicine (EM) resident observed 10 attending physicians over 42 hours during 11 shifts, recording their activities every 30 seconds. Activity categories were developed iteratively by the study team and validated through co-observation by an EM education fellow with a kappa of 0.89. We used regression analysis to assess the relationship between time spent documenting and time spent teaching, as well as the relationship between these two activities and all other attending activity categories.Results: Results demonstrate that time spent documenting was significantly and specifically associated with less time spent teaching, controlling for patient arrivals per hour; every minute spent on documentation was associated with 0.48 fewer minutes spent teaching (p<0.05). Further, documentation time was not strongly associated with time spent on any other activity including patient care, nor did any other activity significantly predict teaching time.Conclusion: Findings suggest that academic attendings may face a trade-off between their documentation and teaching duties. Further study is needed to explore how administrative expectations placed on academic emergency physicians might interfere with trainee education

Documentation Displaces Teaching in an Academic Emergency Department

Introduction: Adverse effects of administrative burden on emergency physicians have been described previously, but the impact of electronic health record documentation by academic emergency attendings on resident education is not known. In this observational study of a quaternary care, academic emergency department, we sought to assess whether the amount of time attending physicians spent on documentation affected the amount of time they spent teaching.Methods: A fourth-year emergency medicine (EM) resident observed 10 attending physicians over 42 hours during 11 shifts, recording their activities every 30 seconds. Activity categories were developed iteratively by the study team and validated through co-observation by an EM education fellow with a kappa of 0.89. We used regression analysis to assess the relationship between time spent documenting and time spent teaching, as well as the relationship between these two activities and all other attending activity categories.Results: Results demonstrate that time spent documenting was significantly and specifically associated with less time spent teaching, controlling for patient arrivals per hour; every minute spent on documentation was associated with 0.48 fewer minutes spent teaching (p<0.05). Further, documentation time was not strongly associated with time spent on any other activity including patient care, nor did any other activity significantly predict teaching time.Conclusion: Findings suggest that academic attendings may face a trade-off between their documentation and teaching duties. Further study is needed to explore how administrative expectations placed on academic emergency physicians might interfere with trainee education

A Video-based Debriefing Program to Support Emergency Medicine Clinician Well-being During the COVID-19 Pandemic

Introduction: Emergency clinicians on the frontline of the coronavirus pandemic experience a range of emotions including anxiety, fear, and grief. Debriefing can help clinicians process these emotions, but the coronavirus pandemic makes it difficult to create a physically and psychologically safe space in the emergency department (ED) to perform this intervention. In response, we piloted a video-based debriefing program to support emergency clinician well-being. We report the details of our program and results of our evaluation of its acceptability and perceived value to emergency clinicians during the pandemic.Methods: ED attending physicians, resident physicians, and non-physician practitioners (NPP) at our quaternary-care academic medical center were invited to participate in role-based, weekly one-hour facilitated debriefings using Zoom. ED attendings with experience in debriefing led each session and used an explorative approach that focused on empathy and normalizing reactions. At the end of the pilot, we distributed to participants an anonymous 10-point survey that included multiple-answer questions and visual analogue scales.Results: We completed 18 debriefings with 68 unique participants (29 attending physicians, 6 resident physicians, and 33 NPPs. A total of 76% of participants responded to our survey and 77% of respondents participated in at least two debriefings. Emergency clinicians reported that the most common reasons to participate in the debriefings were “to enhance my sense of community and connection” (81%) followed by “to support colleagues” (75%). Debriefing with members of the same role group (92%) and the Zoom platform (81%) were considered to be helpful aspects of the debriefing structure. Although emergency clinicians found these sessions to be useful (78.8 +/- 17.6) interquartile range: 73-89), NPPs were less comfortable speaking up (58.5 +/- 23.6) than attending physicians (77.8 +/- 25.0) (p = < 0.008).Conclusion: Emergency clinicians participating in a video-based debriefing program during the coronavirus pandemic found it to be an acceptable and useful approach to support emotional well-being. Our program provided participants with a platform to support each other and maintain a sense of community and connection. Other EDs should consider implementing a debriefing program to safeguard the emotional well-being of their emergency clinician workforce

A Video-based Debriefing Program to Support Emergency Medicine Clinician Well-being During the COVID-19 Pandemic

Introduction: Emergency clinicians on the frontline of the coronavirus pandemic experience a range of emotions including anxiety, fear, and grief. Debriefing can help clinicians process these emotions, but the coronavirus pandemic makes it difficult to create a physically and psychologically safe space in the emergency department (ED) to perform this intervention. In response, we piloted a video-based debriefing program to support emergency clinician well-being. We report the details of our program and results of our evaluation of its acceptability and perceived value to emergency clinicians during the pandemic.Methods: ED attending physicians, resident physicians, and non-physician practitioners (NPP) at our quaternary-care academic medical center were invited to participate in role-based, weekly one-hour facilitated debriefings using Zoom. ED attendings with experience in debriefing led each session and used an explorative approach that focused on empathy and normalizing reactions. At the end of the pilot, we distributed to participants an anonymous 10-point survey that included multiple-answer questions and visual analogue scales.Results: We completed 18 debriefings with 68 unique participants (29 attending physicians, 6 resident physicians, and 33 NPPs. A total of 76% of participants responded to our survey and 77% of respondents participated in at least two debriefings. Emergency clinicians reported that the most common reasons to participate in the debriefings were “to enhance my sense of community and connection” (81%) followed by “to support colleagues” (75%). Debriefing with members of the same role group (92%) and the Zoom platform (81%) were considered to be helpful aspects of the debriefing structure. Although emergency clinicians found these sessions to be useful (78.8 +/- 17.6) interquartile range: 73-89), NPPs were less comfortable speaking up (58.5 +/- 23.6) than attending physicians (77.8 +/- 25.0) (p = < 0.008).Conclusion: Emergency clinicians participating in a video-based debriefing program during the coronavirus pandemic found it to be an acceptable and useful approach to support emotional well-being. Our program provided participants with a platform to support each other and maintain a sense of community and connection. Other EDs should consider implementing a debriefing program to safeguard the emotional well-being of their emergency clinician workforce