Patient satisfaction most be a priority in emergency departments (EDs). The care provided by residents forms much of the patient contact in academic EDs

Bauche, John

Kazzi, A. Antoine

Langdorf, Mark I.

Marwah, Rakesh S.

English

PubMed

Langdorf, Mark I

Marwah, Rakesh S

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Western Journal of Emergency Medicine

Monetary Resident Incentives: Effect on Patient Satisfaction in an Academic Emergency Department

Patient satisfaction must be a priority in emergency departments (EDs). The care provided by residents forms much of the patient contact in academic EDs.Objective: To determine if monetary incentives for emergency medicine (EM) residents improve patient satisfaction scores on a mailed survey.Methods: The incentive program ran for nine months, 199-2000. Press-Ganey survey responses from ED patients in 456 hospitals; 124 form a peer group of larger, teaching hospitals. Questions relate to: 1) waiting time, 2) taking the problem seriously, 3) treatment information, 4) home care concerns, 5) doctor’s courtesy, and 6) concern with comfort. A 5-point Likert scale ranges from “very poor” (0 points) to “very good” (100) Raw score is the weighted mean, converted to a percentile vs. the peer group. Incentives were three-fold: a year-end event for the EM residents if 80th percentile results were achieved; individual incentives for educational materials of $50/resident (50th percentile), $100 (60th), $150 (70th), or $200 (80th); discount cards for the hospital’s espresso cart. These were distributed by 11 EM faculty (six cards/month) as rewards for outstanding interactions. Program cost was &lt;$8,000, from patient-care revenue. Faculty had similar direct incentives, but nursing and staff incentives were ill defined and indirect.Results: Raw scores ranged from 66.1 (waiting time) to 84.3 (doctor’s courtesy) (n=509 or ~7.2% of ED volume). Corresponding percentiles were 20th-43rd (mean=31st). We found no difference between the overall scores after the incentives, but three of the six questions showed improvement, with one, “doctors’ courtesy,” reaching 53rd percentile reward.Conclusions: Incentives are a novel idea to improve patient satisfaction, but did not foster overall Press-Ganey score improvement. We did find a trend toward improvement for doctor patient interaction scores. Confounding variables, such as increasing patient census, could account for inability to demonstrate positive effect

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UC IrvineWestern Journal of Emergency Medicine: Integrating Emergency Care with Population HealthTitleMonetary Resident Incentives: Effect on Patient Satisfaction in an Academic Emergency DepartmentPermalinkhttps://escholarship.org/uc/item/8mz614s0JournalWestern Journal of Emergency Medicine: Integrating Emergency Care with Population Health, 6(1)ISSN1936-900XAuthorsLangdorf, Mark IKazzi, A. AntoineMarwah, Rakesh S.et al.Publication Date2005Copyright InformationCopyright 2005 by the author(s). All rights reserved unless otherwise indicated. Contact the author(s) for any necessary permissions. Learn more at https://escholarship.org/terms Peer reviewedeScholarship.org Powered by the California Digital LibraryUniversity of CaliforniaPage 8 ---- -- --- 3. Pappagallo M. Heinberg LJ. Ethical issues in the manage~nent of chronic nonmalignant pain. Sei~zirzal-s iiz Nezll-ology 1997; 17(3):203-11. 4. Andersen S, keikersfeldt G. Management of chronic non-malignant pain. Britislz Jo~trrzal of Clirzical Practice 1996 Sep;50(6):324-30. 5 .  MacLeod BB. Swanson R.  A new approach to chronic pain in the ED. Ar77erlcar1 J o i ~ r n a i  of Ei~ergerzcy Medicine 1990 May: %4(3):323-6. 6. Hill CS Jr. Government regulatory influences on opioid prescribing and their impact on the treatment of pain of nonmalignant origin. Jourriltl of Pnirz c11zd Synzpro~?? Muizcigenzerzt 1996 May: l1(5):287-98. 7. Miotco K,  Conlpron P~ Ling W, Conolly M. Diagnosing addictive disease in chronic pain patients. Ps~chosor~za~ics 1996 May-Jun;37(3):223-35. 8. Zechnich AD, Hedges JR.  Community-wide emergency department visits by patients suspected of drug-seeking beha\,ior. Acadenzic Enzergency Medicine 1996 Apr;3(4):3 12-7. 9. Parran T Jr. Prescription drug abuse. A question of balance. Medical Clinics of North Ai~qerica 1997 J~1!;81(4):967-78. 10. Drug Enforcement Agency (DEA): Guidelines for prescription of narcotics for physicians, Washington, DC, US Dept. of Justice, U.S. Goverrnineizt Plinting Office 1990:275-114. 11. Savage SR. Opioid use in the management of chronic pain. Med Clirl North Am 1999 May:83(3):761- 86. 12. Cornpton P3 Darakjian 3, Miotto K. Screening for addiction in  patients with  chronic pain and "problematic" substance use: evaluation of a pilot assessment tool. J Pain S J ' M Z ~ ~ O M I  Manage 1998 Dec; 16(4):355-43. 13. Portenoy RM, Dole V, Joseph H. et al. Pain management and chel~iical dependency. Evolving perspectives. JAMA 1997 Aug 20;278(7):592-593. 14. Porter 9, Jick H. Addictio~~ rare in patients treated with narcotics. NE~zgl  SMed 8980 Jan 10;302(2): 123. 15. Eastman P~ New US campaign targets prescription drug abuse, especially painkillers. Elnergerzcy Medicine Ne~vs  200 1 : 1- 12. 16. Scheck A. The burden of drugs. Emel-gerzcy Medicine News 2001:38-39. 17. Staiey D, el-Guebaly N. Psychometric properties of the Drug Abuse Screening Test in a psychiatric patient population. Addict Behav 1990; 15(3):257-64. 18. Gavin D. Ross EI, Skinner- H. Diagnostic validity of clme Drug Abuse Screening Test in the assessinent of DSM-111 drug disorders. Br-ifis7z Jsunzal ofAclclicfion 1989 Mar;84(3):30 1-7. Pat'renh.;atisPaction must be  a pr ior i ty  in emerges-acy depar$~.rtealts (EDsj.  The care provided by residents forms much of the patient coid~tact in acadenlic EDs, OZsjective: To determine if ~s.;_ssnetary incentives for emergency medicine (EhI) resBde91ts improve patient satisfaction scores on a naailed snrlrej-, A4etholls: The incentive prograrfi ran for nine ~nonths~ 1999-2000, Press- Ganay surveys responses from ED patients  BE^ 456 hospitals; 124 for111 a. peer ga-oup of Barge& teaching hss~ f$&.  Qnesbioas yelate 465"1! l!~rai%ing 3 - $%nae, 2) tg],;inn -fi prohleill serlonsly, 3 )  tygafmejlt ir:forn>atis;:, 4) J1okx.e cake ~ n ; ; Y ~ ~ ~ - j . ~ s ,  5'i d ~ ~ ~ , ~ $ ~ ~ ' s  cj;artesy, ;%,nd6 )  concera witfa cnnakrf,, . , - ts  -.- 1- 1.- . , i r ik .o l : s i~~j~  course sponsored by the Bayer insfi",ute. 7r,- , ,. - i h ~ s  seminay was nr?t a p a ~ t  ol the stutiy; and took " -.- place ap~?ri3xh:nntely one-year prlo;: 1 here were no . ~~ other- 5.l)i-lilai training sessicns for doctor-paiieiit relationships, but t11i"i~spes:t of EM pyastice \xji.~a. d;.,'-- ~ ~ ~ . ! . 1 , ~ ~ ~ 1 1 %  .- approximately monthly during regular resident conferences. Resident salaries ranged from $3 1,500 for the PGY I year to $38,000 for the 13GTd3 year, Twenty-three percent of patients are ad~zaitted froln the ED. The Bnstitutional Review Board of the sponsorii~g institutio11~113proved the study. Strich Protocol: The incentive program ran for nine months. from Novernber 1, 1999 througla June 30, 3000. Press-Ganey is the natiora's largest health care satisfaction measurement firm, and processes some six milliolz sunrey s anrzual'liy from o w -  1,000 health care organizations. It benchn~arks responses for ED patients against 456 hospitals, while 124 of eB~esc form a peer group of larger, teaching hospitals. Questions on the ED survey regarding pl-aysician-patient interactions inclirded 1) time to see a doctor. 2) whether the doctor took the patient's problem seriously, 3) whethel-hhe doctor was ir;lforel~ati\~e abw~~t treatment, 4) whether the doctor seemed concerned with home care, 5 )  the doctor's courtesy. and 6) the doctor's concern with patient comfort. Responzses were on a 5-poillt Likerr scale, from "very poor" (0 points) to "very goocY5 (ii00)- The raw score 2s the weighted mean of these ansmrers, which ii; then co~~verted to a percentile T/S. the ED peer group. Surveys were only 3n Englis1-r and mailed to each patient discharged frsm the ED within 2-3 days of their VB sit This study inllolved survey\ of only patient-, who were treated and released from the ED. Kie did this because adlnltted patients receive a bafferent veriion of the Ress-Ganey sur\ley. The Prc-c?s-Gd~zeji ED iuz-vey ha\ 30 qtaestions related to all aspects of the ED \ asit (registration, nLirsing. billang, rreatmel~t of fanaily and friends. etc.). The focu4 of thi5 sttidy W ~ C ,  to demoni@~tte ht~provement 6n the srx phy$ician-cpecific question scores. Hsrn~ever, the Prerb-Garley survey cent to admitted patients Flcuses on their m~patienl stay9 with only four dkRere11t question\ related to the ED po~~ion .  Hence, we excltacied data from inpatient qiuveys. The incentive progranl had thee  components. First, a ye=-end group event would be f ~ ~ n d e d  for the EM rehidents I" the 80h percentile score viere attained on the doctc.1-speciflc survey questions. If not, a graiduated incentive for each resident for educktlional mate~als  would be $50 per residcnt (50th percentile), The Callfoinin Jouin,il ot Einergeilci Pvledlcine VI 1, Jaii-Ma1 2005 - $1 00 (60th), $150 (40thi, and $200 (80";). If the 80L1' percentile were ateir~ed, both "me year-end event a d  the monetary allowance would be hnded. The third cornpollent was $4 gift certificate cards for the hospital's gourinet coffee can. These were distributed by each of I 1 EM faculty (six cards per month) as on-the-spot rewards for witnessed episodes of outstanding patient interactions. Potential cost for the program was a maximum of $8,000. derived fiona the faculty's patient-care revenue. The ED f a c u l ~  had a similar direct incentive plan along similar lines for patielzt s;nkis-ljetion. AZ~ough patient satisfaction was a contilauing instih~tional pfiority for nurses and stafi:, incentih7es were only iladirzctiy rclatecl to patiene satisi'acdcsn scores. Meklszlrer?zenf,~ nnd k q  csufconae nlen,\ul-es: Mean raw scores and percentiles versus the peer grorip of t~ospitals for the above qe~estions were compared "ofore and after the incentive program intervenaion. Data Analysis: We compared the proportions of Likert scale categorical responses using Chi-squared an-nalysia (True Epihtat. 5.0 Richardson, T X )  to deten~zine if the ia~tervention was associated with improven~ent in mean scores. We set statistical significirnce at p < .05. RESULTS Baseline scores for 3 I d  q ~ i ~ s t ~ r ,  i 999, were based 081 a wnp le  sire of 509. !A h i e  second quarter, 2000 rei~ilts wece from a sa~nple S I Z ~  oi 577 (response rate -7 2 5  oo: ED \rol~rme fc\kir each quarter). Weruit., are ~hcwn un the Table was no $~gl~ifican~ d~gerencc;. between zhe oven all phq 4 ~ ~ i a n  \core$ before dl2:id aftcr the amplemenhtaon of the rs7crntIiic plogii-aur, eat hclr - by salA  ore or pcrcent~le, I here was znipsovelnent an t11c p"~nd le  i cc l  es, howex$ er, for overall result5 and for three of thc ssx ~n,ln\ ]dual questiorzs Thss occun-ed derpate decreaicr ln raw scorer for there three qne\tionl, puesulraably as 3 lesi~lt of a pxalBel decljrae in raw rcha;.c\ among the peer group hosp~tal EDs. One quesboal, doctors' couflesy, increased from 41'' to 53" percentlie The faculty {herefore elected to fund the 50th percenlile auiaid at $50 per aes~demt -1 ims wa\jus"rf~ed by lnaamalnang dable ~ o r e s ,  whlle trendmag posrtively, deiplte an ED parlent volume Increase of 10% dur~arg the study period. Total cost of the program -mas therefore $3,@90. Pagci 12 -- . ~. ~ime-constamlag actsvrties might begefit pkbtie~~t . . * ~ < .  satisfij.cb~n m one ;ma, whde worsening s c s ~ s  reidwed . ~ to wairlr,g ~ir-nc, as patient flow slowed ti) provlae more con~fort and patient educatian. *- e j m i ~ g  the s t ~ & ~  period. there were fc~e,rces ah:t3;:lg against the Initiative to iwLprove padent s2Ltisf:lctii~n. T - % '  ra-bent volrrme kcreased by 105%- as did the dkfficult~~ in getting i:~pk~tis,nt beds. This ilni3ai?.ed ability to see new patients, and prolonged waiting time. The other persont~el in the ED, though subject to similar incerntives, may no: have embraced :he pi-~iadigrn shift towad customer siitjsfaction~ rg-iP~o additim-nal faaul~y . * and severdl nurses came to ;.vorE~ in the ED dnzmg tne study pel-iod. These new people may have iiafldenced the level of padent satisfaction. Aa any one time, from 1-3 off-service residents atid I -.? medical studenis work the ED. They were not part of [he incentive program: and, anecdotallj;; ;ire less conscio~rs about customer service. On the positive side- the opeaing - .  of a new modern waiting i ~ d  triage an2a during the study period might have idle~enced scoi-es s~d~s&~i:'ially. . . Thotxgh c0p_$;;idL m"the vwalt;rlg roola;, Increased b5/ ', 0 ~ - points. this ap~>aentlg/ did not infiue~~ci.: the phyiclan.3 scores. R:e~ious ~vofk has sho;.vn tkdt patients wh(lse grhirnay langt~age is  not E~glish ; ~ e  I ss saiisfied with their ED visir. in a popula"lion of 15% non-En~Eis11 b speakers, only 52% ofofi~lients were satisfied with the ED visit (Vs. 7 9? 5% who spoke Eagllsh), and Ggnificantly more p;b"aients (14% vs. 9 5 %  ) wasuid not ret~ii-n to the same The Cailfo'ni-nia jo:~rn,ll of Ei:~ergt.ncy ?v?s~iicine VI: 1 ,  Jai-i-Mar ?i?O5 . ED,? The ED ~n7ider study ha;; 45% noil-El?g!ish spcnp;-a ,, d ~ r g  - patients, which might have mas!ted any positive effect ofthe incentive priagtarn. If h e  faculty has resiaeasces from patient care ::e-ilerzue to devote to an incentive pSen, one n:ight argue that these should "8 directed tcwasd educztiorral zcfvities (books. subscripGons, reside~lt ravel to ccsnferer~ces, etc.). Residency muse teach, however, both clinical and practice skills: A recent su r~ey  of EM reside1:cy qraduares f~>i,und that 57% felt they needed m.ure I_ education in residency on kuxiness a::pects,' In the -.., pactice arena, there is no more important skill than the ability lo forge a successf~d doctol.-patiel~t relationsI$-m;.g?, Ti~xefore, inye~~jng mone>i to foster Eia,,f practice skias is as valid as investing i.n te~iching r:haical i 1 3 1  s . Everi though the incentive piIgl'iX:i did not si~&Sca~'itiy irnpre3ve patj-,nt ~atisfz~ction  cores, we received I .P ~ ~ sapmncanhtte~~tio~:, from hospital ahx~~~stratior~ ;:~d . ~ other reside~acaes rn the process. Merely calling afiell~on to issue in a fcii~naEz:=d i;v'k:y pojjticidy a&alntagems -for the ETd f;i~k;lly, The low response r2ete casts doubt cjll tI1.i; validipv- of . , the srarvey. iJJe &d not test fi3r response bias- as the s ~ ~ ~ - ~ ~ ~ ~ ~ ~  we-.o ,J L"'?"A).~~!~,LL,,. r;liLl 7.7- n r n i .  nvwever? T ? - - T -  the response rate in Ijle stcdy ED js txjpjcaj d . of ctthper urban1 ED?, where respan.; 1.airs for sanlpie siiri.eys are as iou, as 5%;. n r r 3  l~r:2a-qLTp ; 2 & ~ - i  qPi;.t.-4'-:'. .a n u  i u ', . G.b d Ltcii b l ~ ~ h  of t e r-espcnse rate, the outc~. '1 r ~ S L  o -i~ . , .~ : :~ i rc  -tsnr.--.r- ii, ntsl the raw bcore, bill . ~. the pepcenfile soa;-kp--:;oi~ to i-iace In~:~piti;%s. An such, gb)(;i response rates arc iibiquita.is, lile~efpfc a;cmnaris(~lls betiveen valid. -fr: addjljoil, resp<;nse r ~ ~ t e s  3n stl~gLfir ED :s;e:re tj3j: same befcxe &a,r the ntem-.ilei~tdon, sliggest-ine that the bias ~. :nherent in  a 1.esponse rate was stable. ~ e ~ ~ ~ L ~ ~ ~ s  lo be seen if appl y imlg a consiste~a incm'ive across 121 ED personneli notjust resicients, ~?vo~%id afle~"I a ~ y  ienprovement in patient sarjsfaction scores, It is possrble that rfionetxy ~nodvahon 3s insuficient in itself? to improve di~ctor-patient .i.elationships. Formal education promoting technjqrres to improve cor.nzl~-sunica"sm ay be necessary as v~e14. Finally, this study raises new questions that EM educators and acadeanic leadel-s sl~ould address. In TIie citlifcj:ir:?a Jcum:,; !.>i'Eiile:-ge:?cy h/!-dicine VI: 1, Jar:-k?nj. 2";'15 ~ - Page 13 ----- --, ~" : the ena;ironpLei-,t, uruei:lere 2-caj~en?jc i;a.:tl'tajbofis thek leaders are c:.rpec&ed to compete the ~;k;-ib&y of their &i.I :ling p o p a l ~ s ,  si.,i;;iuld s~lbsta1llial n:onetzry irlcenajx;es l ~ e  2L&yp;ed far 1esikntu.f ubuld .," CIUT l ~ n d i n g ~  have heen diffefer,t had used ~ . -  - ~ u b s t i : I " , t ; a ~ d ~ ~ ~ < ; ~  jm,eal~ijes t3 ~ f i ~ ~ \ : ~ ~ i . ; a ] s ,  rather a:han ~iraup rewards :x credits far aa:ademic materials? L Shoiiid financial or nun-nlonetary deterrents be 3 r qv-"-" <- % '" c:oa-ssider-ed for D O O ~  pc, f Li rr,d~,i,e? Aim ir~cen~ive program rzsidents is a novel idea to attempt to i;rkprove patient satis&~ctioi~. "@e did no; ~ ~ show any s:g:~rficant improvement related to the prog2111~ but maintenance of the pbvsickan's standing ab; the hest perfdrming group in rhe ED is Iatrdable given the increas~d patient volume. Confounding variables castild account for changes in scores over tinhe. The :wk:gnitude, durai-on aiid/oris~~plen~:nta~on of the ~ ~ c e ~ ~ t i v c  pc>g-;-a:-1., wou?ld need to be augrnelatecl " ~ 10 nlake ljxs liltely:eniionr ;i7liiflh11:~~hj 1 e,1. T r o ~ i l  A, h~Izgnussn~: HR, Hedges JR, Patient Sat4sfacti~1.n ln\.es%igai;ions and the Emergei~rji --, - ' . . aeparment: 'What Doe j lkle L_lrej-ari;:s Say? Acnt/e;iric - k?li.p;~r;.ili.y jvfttt/ic.iile 2()00;7:6$4_5-?09. 2.' -,-...-. * * *  <- - -. c,:l; clsqull;cj 0, Crnj, b,;!, &rennail 'TPP, Burstii: HR, Ifiiilact if ~ , a f i ~ ~ i ~ g ~  - B ~ , ~ r ~ . e : . ~  011 E'z"iient Saiisfacrir:il in an En;e:-eefii.\i $- ., Depa&ment. Je~li i . i l tr /  :,J ~r i r i~ l -~ l /  /llfej-ajti~ J,j'erjic'lje; lg$gl 14183-7. ? V'i-s~i-o S, Sucv D_-p. Kalje!?Rom JC. Coieman RD -I I L*, "! ;> _;< .;*> ,,,,., -7: ill. t-i: Dei;oyl~apflic Prai.Gce se[ecl.io;; 8 .  -- r>: :il.;-ereei:cx/ Ibfed:icine Gradui:ies from a;; - , -gll>t3>,na7 ,, i , l L :  L . , i +  ,.\, ;.:l,Sicitle ,<!  a Trai:;jne "ro~ram. SABM - -  - u ."- tl<> -7 q ,  Lster:l Regional R ~ ~ G ~ . T C I ?  ~ - ~ . u ~ ~ .  2001 (&stracr! /I - 4. Feri'?i..i . . - - 1 1  -0 T \  .;,,, ",~i?mfi'ri~n:~aiic~:2. a17311;'~ e ~ e s ~ i ~ $  a hij,,, ,&nii)i. v - - - , ~ >  iii:;sLurc:ii .iihsr!ci:r~e. Press, Ganey jissnr:ia"i~s. Zrlc.. -fi '>P> , L \ I ~ \ ~ L # .  

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Monetary Resident Incentives: Effect on Patient Satisfaction in an Academic Emergency Department

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