OSF Emergency Room Patient Satsifaction

Emergency Room Patient Satisfaction

The OSF Emergency Room patient satisfaction as reported in the Press-Gainey statistics was very low. When I was fired in December, ‘01, the reported patient satisfaction was 33%, the lowest at OSF-SFMC. I sure didn’t have all the answers to the problems of the ER, but I thought that the ER Directors, Rick Miller and George Hevesy, were not forceful enough with OSF’s administration. They seemed to be lackeys for administration. They didn’t seem to advocate enough for the ER.

The ER seemed to be on the “backburner” compared to other OSF projects like the construction of the OSF Center For Health—the new OSF facility that costs 10’s of millions of dollars and positioned in north Peoria. At an Emergency Department Staff meeting in 2001, mention was made of the lack of pillows for our patients’ stretchers in the ER. An attending physician (not me) even stated he would borrow a friend’s pick-up, go to Wal Mart and buy pillows with his own money for the emergency room. This offer enraged Dr. Miller at the meeting because it showed how far the ER had plummeted under his watch. Miller was on his way out the door as Director and wanted not to inflame administration any further as he cut himself a nice deal as a “regular” ER doctor.

I stated to Miller over the years that I did not think we had good control over the environment inside the ER. I thought the ER was dysfunctional. I told him it was like practicing medicine on a street corner in Haiti. Miller asked me to write down my comments for the Patient Satsifaction Committee which I did on February 8,2000.

Here are excerpts from my letter:

“Patient Satsifaction Committee:

Rick Miller called me into his office after hearing second hand my comments at your Patient Satsifactiion Committee meeting. I offered to put into writing some thoughts and suggestions concerning my perception of our ER since I have spent the majority of the last 20 years of my life at OSF-SFMC. (Since 1989, I had spent more hours on line seeing patients in the OSF ER than any other physician in the department.) Rick asked me for specific suggestions regarding patient satisfaction or lack therof.

1. As I stated quite clealy last week, the ER needs to become the central focus of the Emergency Department. Our individual agendas, problems, and distractions need to be muted and care of the patient needs to take precedence over other matters. The patient needs to become the center of focus for attendings, residents, nurses, and everyone working in the ER. At the present time this is not the case. This concept is quite simple and definitely not original. We seem to want to make all of this harder than it really is. Thousands of dollars will be spent on teaching us how to act and what to say. This shouldn’t have to be the case. Should we need outside speakers giving us pep talks? We should be more adept at communicatiion and attempting to achieve patient satisfation than anyone in the hospital.

2. A number of employees have left the ER recently. Why? What is wrong? Our leaders need to look very carefully at this issue. The right questions have to be asked. Respect for each other is often lacking. Disagreement and reasonable dissention should be fostered not squelched. Nurses and doctors and everyone should not be afraid to make suggestions. I know many are… Open face-to-face discussions should occur. There shoud be zero tolerance for gossip and innuendoes. Happier employees could beget happier patients.

3. Attending physicians need to spend quality time with patients. At their bedside. When time permits, residents should present appropriate cases at the bedside with the patient and family listening and contributing. The patient’s nurse needs to be in the room. This would show her interest as well. I frequently solicit the nurse’s advice as to what she thinks is going on with the patient and frequently do what the nurse tells me. The nurse would automatically be reintergrated as part of the decision making process that is unfolding. Duplication of efforts would be reduced tremendously. Patients would sense an effort on their behalf. Watching us read real estate magazines at the nursing station would be supplanted by patient medical staff interaction.

4. The noise pollution and interruptions in the ED are huge problems. I believe that if most interruptions were actually analyzed, 90% would be unnecessary. ICU’s don’t allow it. Surgery doesn’t allow it. Caterpillar doesn’t allow it….This cacophony of activity that plays out daily in the ER shows no respoect for the paitent who we are attempting to satisfy. It disrupts thinking, history and physicals, reading medical records, teaching, and most of all quality of care rendered to the patient.
So how can we decrease these distractions?

Here is a partial list of my suggestions:

Think before you yell at someone across the ER. Is it really necessary to yell it?
Idle chatter, cursing, and whistling Chrismas carols should be prohibited. (Respect for the patient and his condition needs to be shown.)
Over head announcements should be kept to a bare minimum by everyone.

Limit two visitors per patient at a time. There is simply too much traffic in the ER.
I counted 20 people (staff, EMT’s, etc.) mlling around talking outside of the nursing station on one occasion. Frequently it is diffficult even to get a booth to chart.

Remove medical communications from the ER or staff it full time with someone dedicated to that and only that. ( I put this in because it was very time consuming and distracting to answer these calls. Hevesy was in control of all ambulances in central Illinois and OSF was and is the resource hospital and base station. All radio calls from ambulances came to OSF ER whether the patient was coming to OSF or not. Doctors had to answer the calls, write up the conversation, call the receiving hospital, and have the chart faxed to the receiving emergency department. It was helpful at times to the patient, but could have been handled by the receiving hospital because they were listening to the call as well and the EMT’s on the ambulance followed protocols that had been established by the project medical director anyway. I thought that the job done by the EMT’s and paramedics in the Peoria area showed sincere care on their part and their notes and my conversations with them in the ER was very valuable to the care of the emergent patient arriving by ambulance. The EMT’s, volunteer fire departments, municpial fire departments, and AMT paramedics and EMT’s found themselves in very tough circumstances with many patients. I didn’t know in 2000 that Hevesy was on the payroll at AMT and for him to show his power base at OSF with medical communications was important to him for reasons that I did not know. Answering the radio pulled us away from our patients already in the ER at OSF and delayed and fragmented their care all the more. )

5. As I said last week go back to the basics of any primary care specialty–the ABC’s. This is often the hardest for me to do but the most important. Emergency Medicine is not rocket science. We need to do accurate appropriate vital signs. Attendings and residents need to learn how to do vital signs again. The physical exam (not technology) needs to be resurrected and utilized. The patients need to be undressed in appropriate clinical scenarios. Continuous pulse oximetry and telemetry frequently does not constitute appropriate or even necessary vital signs. Frequent reassessment of the patient at the bedside by the doctor and nurse is difficult but necesssary.

As you all know I want my family and friends to come to this Emergency Department and OSF-SFMC when sick or injured. Central Illinois is very blessed to have this medical comples.

I finished the letter as follows:

A ton of money and new technology is not necessasry. Common sense and making the effort to do a good job is necessary. People in the trenches like me need to do the basics over and over in a friendly and structured environment that gives the patient a chance. Our leaders need to listen, suspend political and ecomonic agendas, and refocus on the ER and its people.

Respectfully,

John A. Carroll, MD

Only two people on the Patient Satsifaction Committee responded to my letter and behind closed doors told me that they liked it. I think most others were afraid to say anything because of the content of my letter and the issue about medical communications because that was Hevesy’s baby.

In the fall of the following year as I was under indictment at OSF, Hevesy told me during one of my meetigs with him that the ER had been without a leader for one and one-half years. He told me that he would be frustrated also. Keith Steffen even said there were “deep problems in the ER” and leadership problems in the ER (phone conversation November, ‘01). Tim Miller, assistant administrator at OSF, told me that the “OSF main campus had been ignored.

After I was fired in December, the patient satisfaction rate continued to be very low and an employee satisfaction rating from the ER at OSF came in close to last in the hosptial. 18 ER nurses had left and 12 travelling nurses had been hired by the ER. The ER head nurse was let go partially due to lack of confidence in her by other ER nurses. (She was promoted to OSF Corporate.)

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The Elderly Black Lady

In December, 2000, an elderly Black lady came to the ER for evaluation. She had a few family members with her. The lady was placed in ER room #17 which is in the back hall. She was evaluated by the nurse, resident physician, and me. However, after several trips by me to see her, it seemed like not a lot was being done for her by any of us. She was waiting too long which was not uncommon in the OSF emergency room.
I wheeled the lady up to the nurses’ station and put her under the flow board. This was the center of the ER. Many of the employees in the ED were at the nursing station hanging out. I calmly stated to her that “maybe now you will get some attention”. I went into a nearby room and began with another patient who presented with chest pain.

The nurses at the desk immediately started an IV in the lady under the flow board and moved her to closer room. Her care picked up quickly.

This was reported to Rick Miller by the nursing staff that I had pushed the patient to the center of the ER. Miller told me that this “incident” had a “disruptive effect on the department and represented the department poorly to the patient’s family”. I asked Miller if the family complained about my actions and he said “no”. Obviously, the center of focus for Miller and the nurses who reported me was not the patient’s care but the family’s perception of the ER staff. If my action was disruptive, and caused some action for this patient, I was doing my job.

Miller went on to say very clearly that my action was inappropriate and if I did the same thing again, it would affect my ability to continue working in the Emergency Department. I thought that the delay in the patient’s care was inappropriate and had hoped that Miller would support me, but he did not. Miller would not challenge the nurses. The ER head nurse would go to Sue Wozniak, Chief Fianancial Officer at OSF, and Miller did not want any part of Wozniak for many reasons.

This “disruptive and inappropriate action” on my part was the beginning of the end for me as reflected in Miller’s notes of our conversation.

posted by John A. Carroll, M.D. | 4:34 PM
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June 23, 2006

In the last couple of days, two sources have agreed that hospitals and emergency departments in the U.S. are sick. Cal Thomas and The New York Times both report that we are in the middle of a hospital crisis.

Quoting from both articles, the important points are as follows:

1. 114 million people sought treatment in US emergency departments in 2003.
2. People without insurance or on Medicare are often refused treatment in physician’s offices and sent to local emergency departments. Hundreds of thousands of seriously sick people are diverted from overcrowded emergency rooms filled with people getting care for illnesses that are not life threatening and could have been taken care of in an office or clinic. To help “unclog” emergency rooms will require extending health care coverage to uninsured and providing more primary care clinics and doctors in poor neighborhoods.
3. Hospitals are overcrowded and patients wait in the emergency rooms for hours for treatment and disposition.
4. What is not known is how many people die as a result of delays in treatment or inadequate care under chaotic conditions in emergency rooms.
5. Cal Thomas prefers “systems thinking” as opposed to pouring billions of dollars into a federal agency to fix the problem.
6. Thomas defines “systems thinking” as “basically how you see things. Instead of seeing a huge mess with one problem piled on top of another, you see differently. You see with what people call “new eyes.” You see how you and your work fit into the system, and how you and your work connect to the other people in the system.”
7. Systems thinking is being tried at several hospitals throughout the country, reducing patient waiting time, dramatically cutting costs and delivering quality care to patients, making them happier and healthier. It has also resulted in doctors, nurses, and other hospital workers enjoying their jobs more. With systems thinking, the patient comes first.
8. The question remains, “Can we afford not to heal our hospitals?”

Putting the patient first will solve most problems encountered in medicine.
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