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emergency department

Patient Satisfaction Must Start With Nursing Satisfaction

Posted on Wed, Nov 16, 2016
Patient Satisfaction Must Start With Nursing Satisfaction

By Alberto Hazan, MD

Ever since the U.S. government decided to link Medicare reimbursement dollars to patient satisfaction scores, hospital administrators have been obsessed with improving the quality of care for patients visiting their emergency departments. While the motivation may be partly financial, the goal of improving the patient experience during emergency department and hospital visits is an admirable one.

Unfortunately, many of the tactics used by administrators have done little to achieve that goal. Hiring national “experts” on customer service to give lectures to the hospital staff, or introducing catchy mnemonics to guide physicians in conducting more compassionate patient interviews, have been equally ineffective in markedly improving patient satisfaction.

If we aim to better the patient experience in the emergency department (and the rest of the hospital), we need to shift our focus from the patients to the nursing staff. After all, the people who spend the most time with patients are not the physicians but the nurses. If nurses are dissatisfied at work, patients will inevitably be dissatisfied with their experience.

Recent discoveries in the field of positive psychology have demonstrated that being successful in any endeavor (including improving patient satisfaction in emergency departments) requires happiness as a prerequisite. If we truly want to improve the safety, care, and experience of our patients, then we need happier people at work. In his book, The Happiness Advantage: The Seven Principles of Positive Psychology That Fuel Success and Performance at Work, Shawn Achor highlights the link between success and happiness: “Studies show that simply believing we can bring about positive change in our lives increases motivation and job performance; that success, in essence, becomes a self-fulfilling prophecy.”

Ensuring we have happier nurses won’t just improve patient satisfaction; it will, more importantly, improve the safety and well being of anyone being treated in the emergency department. Happier people are more aware of their surroundings, they take more pride in their work, and they’re less likely to make mistakes. In the ER, this is imperative. A happier, more engaged nursing staff will be able to recognize red flags (including physician error), identify septic patients, and stay on top of their workload.

Ultimately, success in the emergency department means many things: taking good care of patients, looking after their best interests, and ensuring they do not have a life- or limb-threatening illness. Being successful isn’t just about improving patient satisfaction scores. It also means taking care of patient anxiety, treating their pain, and making them comfortable. It means that nurses (and physicians) are in a state of flow, can handle stress, and are aware, in the moment, and conscious of what they’re doing. This will help them work better as a team. Being happy at work also provides nurses with self-confidence and self-esteem: “The more you believe in your own ability to succeed, the more likely it is that you will,” says Achor.

If our nursing staff is happy, they are likely to see working in the ER as a calling rather than a job. In other words, “people with a calling view work as an end in itself.” Achor makes a case that happy employees have different priorities beyond just earning a paycheck: “Their work is fulfilling not because of external rewards but because they feel it contributes to the greater good, draws on their personal strengths, and gives them meaning and purpose.”

When nurses view their work as a calling, they can see more clearly the benefits they provide to patients, such as alleviating pain and suffering, quelling anxiety, diagnosing illness, and providing compassionate care.

How to Engage Your Nursing Staff

I recently became the director of the emergency department at Desert Springs Hospital Medical Center in Las Vegas. As soon as I took over the position, my mind reeled with the changes I wanted to make to ensure that patients were adequately taken care of, treated with respect, seen in a timely manner, and that their pain, anxiety, and questions were addressed quickly and effectively. I soon realized the most effective way to bring about such changes is to make sure that the people spending the most time with those patients—the nursing staff—are adequately taken care of.

I’ve started asking nurses about their goals and frustrations. I don’t schedule meetings with a bunch of doctors to figure out how to best improve patient satisfaction, but rather I ask the nurses themselves, individually and in real time:

  1. What is your overall satisfaction working at our hospital?
  2. What is the most stressful thing about your workday?
  3. What can we do to improve your workday?
  4. Do you feel rested? Do you have enough breaks?
  5. Do you enjoy working with your colleagues? Is there anyone here who drives you down?

I’m not sure what changes will come out of this. Maybe we will mandate an 8-hour workday, or provide a better schedule. Maybe we will increase our staff, or make sure nurses don’t waste time on non-clinical chores like finding equipment. Maybe we will promote more social events, or have more discussions in real time, especially after traumatic experiences like the death of a pediatric patient or a major resuscitation, to ensure hospital staff deal with the grief inherent in treating dying patients.

Regardless, I’m starting the process where I should: focusing on the people at the heart of patient care.

Dr. Alberto Hazan is an emergency physician and the director of the Desert Springs Hospital Medical Center Emergency Department in Las Vegas. He is the author of the medical thriller Dr. Vigilante and the preteen urban fantasy series The League of Freaks.

This post originally appeared on


Featured Clinician: Eric Schuck, MD, FAAP

Posted on Wed, Nov 09, 2016
Featured Clinician: Eric Schuck, MD, FAAP

The heart and soul of our practice are our clinicians. Meet Eric J. Schuck, MD, FAAP, assistant site medical director of the emergency department at Fort Walton Beach Medical Center in Fort Walton Beach, Fla.

Years with EmCare: 3 years.

Years practicing medicine: 19 years.

Why did you decide to become a doctor? Why did you choose your specialty? I decided to become a doctor to serve others. I chose pediatric emergency medicine because I love caring for children and families. They are vital to our future!

What career did you want to pursue when you were younger? I wanted to be a physician!

Describe one of your greatest professional accomplishments. I was able to diagnose a 15-month-old with leukemia after others had failed.

What is in the pockets of your lab coat? I don’t wear one. It scares the patients!

What would be your ideal category on “Jeopardy”? “Movies” or “80s Music”

How do you stay organized at work? I always have my smart phone and iPad.

What are your tips for “leaving work at work” and not getting burned out professionally? I immerse myself in my family when I hit the front door.

How are you Making Healthcare Work Better®? I’m focused on driving efficiency, teaching our advanced practice providers and serving as medical staff president.

What’s the best advice you’ve received about work or life? Your kids are only young once – don’t miss it!

What do you enjoy outside of work? My kids, going to church and fitness activities.

What qualities make a successful doctor? Focusing on service, compassion and a desire to learn and teach.

How would your co-workers describe you? I think they’d say that I’m humorous, committed and fair.

Tell us something that most people at work don't know about you. I love to sing!

If you could have dinner with anyone, living or historical, who would you choose and why? Ronald Reagan, because he was the last true American leader with integrity.

What are you currently reading? “Great Again: How to Fix Our Crippled America” by Donald Trump

What’s your favorite TV show? “Vinyl” on HBO.

What personal accomplishment are you most proud of? My children – all five of them!


Implementing Lean Processes in the ED Improves Metrics

Posted on Wed, Oct 19, 2016
Implementing Lean Processes in the ED Improves Metrics

By Christine Kelly, RN, MBA, FACHE; Amanda Maxim, RN, BSN, MBA; Jan Beck, RN, BSN; and Shayne Middleton, RN, BSN, CEN

Nowhere is a glitch in the patient experience more pronounced than in the emergency department (ED). The ED team's ability to provide fast, efficient, quality care has a signifcant impact on each patient’s perception of care and the management of life-threatening injuries.

The processes in use today to manage patient flow from arrival to treatment to disposition are widely seen as inefficient and cumbersome. These inefficiencies often lead to long wait times and a lack of attention to patient needs and, potentially, prevent needed access to care. Recent publicity surrounding patients leaving without treatment, deaths in waiting rooms and overcrowding has become a catalyst for change in the industry. As a result, we are seeing a significant increase in the use of lean at hospitals nationwide.

It’s important to understand that achieving lean in the ED may rely heavily on improving processes in other departments. Lean can be most effective for improving patient throughput, but this means looking at the ED as one part of the delicate ecosystem of hospital care. While lean implementation may start in the ED, to be most effective it needs to extend through all patient flow paths.

When lean is applied to the front-end processes, patients can be seen more quickly. Lean in radiology and ancillary services also can facilitate patient treatment and diagnoses more quickly. Extending lean into the inpatient setting helps cut unnecessary hours off of the length of stay, which opens inpatient beds for new patients to be transferred from the ED. Lean for the OR helps ensure efficient operation of surgical services, allowing accommodation of emergency cases. Lean methodology works best when it encompasses the entire path of patient care.

Implementing Lean in the ED

A lean consultant was asked to conduct an emergency department lean rapid redesign workshop with the goal of improving operational efficiency.

Patients were experiencing an increased length of stay due to delayed diagnostics. Further, without use of pre-emptive orders at triage, it was taking 35 minutes from arrival to order entry by a primary care nurse if immediate bedding took place (and longer if no beds were available).

  • Patient presents to triage = 30 minutes; to room 110 minutes, wait for provider 60 minutes, Medical Screening Exam = 10 minutes, 5 minutes to order entry = total of 215 minutes from door to order entry
  • Provider order entry was 74 minutes from arrival
  • With pre-emptive ordering at triage, 24 minutes to order entry
  • LWOTs were two times the national best practice of 2.0 percent
  • Decreased efficiency ancillary services secondary to wasted time/trips to the ED

Contributing conditions:

  • No prioritization of services ordered – X-ray may collect the patient prior to lab draw, resulting in delay in results due to collection time
  • Transport of lab specimen delayed, placed in box on counter
  • No communication between ancillary departments
  • Pre-emptive orders not consistently used by nursing
  • Inconsistent "pull ‘til full"
  • Some physicians delaying medical screening exam on low-acuity patients, some saving for advanced practice providers

The Lean Solution

The consultant worked with the hospital’s nurse leaders to reach the following goals:

  • Implement bedside triage and registration process 100% of time, with “Pull ‘til Full” concepts (Patient-Centric Care) implemented across all shifts/staff
    • Minimize redundancy
    • Standardize triage process
    • Target arrival to provider time: 40 minutes
    • Bed to provider time: 25 minutes
  • Create more organized patient flow with space for simultaneous processes to take place, eliminating wait time and redundancy
    • Adequate resources in the right place
    • Keep vertical patients vertical and give the beds to the sick
    • Use discharge sub-waiting area
  • Consider plant flow redesign with existing spaces to include reassignment of current rooms for more efficient flow
    • Use of triage preemptive protocols 70 percent of the time
    • Improved ancillary communication
    • Collection to receipt of specimen to take only 5 minutes 90 percent of the time
    • Door-to-doc time to meet 40-minute benchmark
  • Educate ED, evaluate cost and benefits, recognize waste, plan-do-study-act, gemba walks
    • Reinforce "pull ‘til full" policy with 100% use of bedside computers
    • Educate nurses/providers in use of pre-emptive protocols
    • Flag on specimen box as visual cue for specimen awaiting transport, ED to assist
    • Lab access to private tracker board to allow comments
    • Lab to notify nursing when draw complete so tracker can be updated for X-Ray
    • Educate Radiology staff on use of tracker notifications
    • Metric comparisons

After implementation, the team’s results included:

  • Streamlined patient flow
  • Decreased throughput time
  • Decreased left without being seen (LWBS) rate
  • Improved patient and employee satisfaction
  • Improved quality in delivery of care
  • Reduced financial losses

EmCare recently published “Making Healthcare Work Better™ with Lean,” a book and supporting workbook developed by the company’s clinicians and operational experts to help hospital leaders and process improvement teams better understand and implement lean process improvement techniques.

This case study is one of many included in the book, which is a compilation of lean experiences and advice from nearly 30 practicing experts. The book is accompanied by a free, downloadable workbook with practical tips and exercises to help you break down barriers to getting lean in your organization. It’s the perfect reference book for someone who needs to understand what lean is about, how to make it work, how to overcome road blocks and how to gain buy-in.

To learn more about this case study and to download your free copy of “Making Healthcare Work Better™ with Lean,” visit our website.

Christine Kelly, RN, MBA, FACHE, is Vice President of Clinical Services for EmCare. Amanda Maxim, RN, BSN, MBA, is Vice President of Clinical Quality for Valesco Physician Services, Inc. Jan Beck, RN, BSN, is a Director of Clinical Services for EmCare. Shayne Middleton, RN, BSN, CEN, is a Divisional Director of Clinical Services for EmCare.


Featured Clinician: Jeff Davidson, MD, FACEP

Posted on Wed, Sep 14, 2016
Featured Clinician: Jeff Davidson, MD, FACEP

The heart and soul of our practice are our clinicians. Meet Jeff Davidson, MD, FACEP, the Medical Director of the Emergency Department at Valley Hospital Medical Center in Las Vegas.

Years with EmCare: 18 years

Years practicing medicine: 22 years

Why did you decide to become a doctor? I had many positive influences when I was younger that opened my thoughts to becoming a physician. My father practiced podiatry and was a great influence on both me and my sister, who practices anesthesia. I learned that the practice of medicine was a lifelong commitment of learning, training and practicing. I was drawn to the idea that you would continually need to challenge yourself to stay atop of practicing medicine. I knew that my personality and drive were ideally suited to becoming a physician and committing to taking care of others.

Why did you choose your specialty? I chose the specialty of emergency medicine because I knew I had the attributes to succeed in the practice. I enjoy the challenge of multitasking and thinking quickly.  I also knew I would enjoy the day-to-day challenge of not knowing what might happen next. Emergency medicine also trains a doctor to be able to engage in other aspects of medicine. EM physicians are naturals for providing medical direction for EMS, sports teams, athletic programs, AED programs, specialty guidance for airlines, cruise ships and more. I also wanted to practice a specialty that would be able to work with all other medicine specialties, and EM is the only choice that provides that access.

What career did you want to pursue when you were younger? I've honestly always been attracted to practicing medicine. 

Describe one of your greatest professional accomplishments. I've been fortunate to have many accomplishments of which I am very proud. I have been the Chairman of the Valley Hospital Medical Center ED for more than a decade. During that time, I helped develop the first Certified Stroke Center within the Valley Health System at our ED, and was named the 2008 Emergency Department Physician of the Year by the American Heart and Stroke Association. In 2010, I helped develop the first hypothermia resuscitation program in our system. I've also had a successful career working in the sports of boxing and mixed martial arts (MMA). I was a Nevada state athletic ringside physician for 10 years before becoming a medical consultant to the UFC and The Ultimate Fighter (TUF). I still work as the chief independent medical consultant for those organizations.

What is in the pockets of your lab coat? I prefer to stay light on my feet; I carry only a list of the patients I'm attending to and my cell phone.

What would be your ideal category on “Jeopardy”? Travel

How do you stay organized at work? It’s a mindset. You need to develop a systematic way of dealing with the multitasking of emergency medicine. I use a chronological system as my day and work continue on. I'm diligent in completing the earliest tasks as a priority if possible. I keep things simple this way and don’t delay or forget.

What are your tips for “leaving work at work” and not getting burned out professionally? I enjoy work; this is the first priority for every doctor. When I’m in the ED, I'm 100% engaged in my work and the people and patients around me. When I leave work, I go straight to the gym most of the time. This provides a transition from the chaotic environment of the ED to my personal life. I think the best ways to remain excited about working in medicine are to prioritize your interests and diversify yourself.  Make sure you work enough that you get a positive experience from being there, and participate in as many other activities as you want to fulfill yourself. These activities can be family, personal sport activities and goals, or other types of work that contribute to your total development. The main thing is to not do too much of just one thing, but become good at many things.

What’s the best advice you’ve received about work or life? Wake up every day ready to take on the challenges of the day. No day will ever be the same, therefore, you will always have something new to learn and new tasks to complete. There will be many days that are difficult. Learn to master these days as well as your best days.

What do you enjoy outside of work? I work out in the gym one to two hours a day. Many days are with the same group of individuals or my two sons. I enjoy working with the MMA athletes I do medical consultation for, and travel to many of the UFC events. I also enjoy working as the medical consultant for The Ultimate Fighter reality show.

What’s your favorite inspirational quote? I always say, "Do or do not, there is no try," which Yoda said in Star Wars. I feel this is the best way to accomplish the most.

What qualities make a successful doctor? Understanding, patience, caring, compassion, dedication and perseverance

How would your co-workers describe you? Dedicated, perseverant, compassionate, hardworking and driven

Tell us something that most people at work don't know about you. I'm actually a very private person.

What are you currently reading? "Tough Jews : Fathers, Sons, and Gangster Dreams" by Rich Cohen. I read mostly nonfction, but intermittently I review "The 48 Laws of Power" by Robert Greene.

What’s your favorite TV show? House of Cards, Blacklist and The Walking Dead (yes, I enjoy the drama!).

What personal accomplishment are you most proud of? Raising my two sons successfully and my attention to personal health.


Studer Spotlight: Improving Patient Experience for Emergent Admissions

Posted on Wed, Aug 31, 2016
Studer Spotlight: Improving Patient Experience for Emergent Admissions

Since 2010, EmCare has maintained a strong partnership with Studer Group to improve clinical and operational results for our client hospitals. As a result of this partnership, Studer Group has provided access to exclusive content only available on Each month, one of Studer Group's insightful articles will be made available to blog readers. For more information about EmCare's partnership with Studer Group, click here. For more exclusive content, including webinars, learning labs, networking opportunities and more, visit

By Stephanie Baker, RN, MBA, CEN

With as high as three quarters of all unscheduled hospital admissions coming through the emergency department (ED), the overall patient experience hinges on how patients perceive the care they receive in the ED. 1

For those with hospital admissions greater than 90 percent from the ED, the patient satisfaction stakes are even higher. Recently a hospital senior leader asked our team what more they could be doing for patient experience given their high percentage of emergent admissions and correspondingly low percentage of elective admissions which tend to report an overall better patient experience.

Below are three strategies we recommend for driving a positive patient experience:

  1. Fast track all direct admission patients or elective patients to protect their arrival experience. The goal is for patients to be admitted and in their bed within 60 minutes of arrival. It is imperative that patients receive effective communication using AIDET® so they understand the plan for their care and feel comfortable. Nurse leaders should round on all new admissions within the first 12-24 hours to welcome them to the unit, provide relevant information, and let patients know that they will round on them daily during their stay. Although this may only apply to a small percentage of your admitted patients, it helps streamline and hardwire an effective admission process and creates a positive first impression. Be sure to validate patient turnaround times daily to see how close you are to the 60-minute arrival-to-bed goal. This lets you know if the process is working and holds admitting and patient placement staff members accountable for results.

  2. Expedite ED admissions based on acuity and length of stay. This is an inherent goal of every ED, but when a large percentage of all hospital admissions come through the ED, the approach must be relentless. Here are a few best practices that can help get the job done:

    • Patient placement coordinators or related roles should round together with the ED manager and charge nurse every four hours to talk to patients to keep them informed and ensure the patient’s clinical status is appropriate for the unit selected for admission. This keeps everyone updated on the status of patients and informs decisions about prioritizing admissions.

    • Inpatient nurse managers should round on ED holding patients at least once a shift to introduce themselves to patients, assess clinical status, ensure admission orders are in progress, and show care and compassion to the patient. This is a big win for both ED holding patients and ED staff as it demonstrates partnership and ownership. The CNO plays a big role in the quality of the experience for ED patients.

    • The CNO should round with the ED Manager on all patients with hold times greater than four to six hours and then round again with those same patients within 24 hours of arrival on the inpatient unit. This sends a strong message to staff and patients that expediting care and admissions from the ED is a priority and helps the CNO assess how well the admission process is working and what specifically needs improvement. To drive accountability and transparency, the CNO will want to review admission process metrics daily at patient flow meetings. Lastly, the CNO provides coaching for leaders who are underperforming and leads sub-groups for areas that need process improvement.

  3. Focus on your care transitions. Effective and safe handovers from the ED to inpatient units are critical to patient safety and clinical outcomes. Of all the patient experience measures included on the HCAHPS survey, care transitions has the highest correlation to overall patient satisfaction. Yet based on national averages, most organizations are not getting it right. There are some best practices for ED to inpatient care transitions you can implement and you should also consider the impact of handovers happening across the continuum of care.

1 American College of Emergency Physicians. (May 2015)

Stephanie Baker

Stephanie Baker has over 25 years of clinical nursing and administrative experience in the areas of Emergency, Trauma, Flight and Critical Care medicine and proven results with her partners around the country. She is a graduate of San Diego State University, has a Bachelor of Science in Nursing and a dual Masters degree in Business Administration and Health Care Management, and is a Certified Emergency Nurse. She is a past recipient of the prestigious “Tribute to Women in Industry” (TWIN) award, a nine-time Studer Group Pillar award winner, and the recipient of the prestigious Studer Group “Flame” award.

Baker is the Emergency Services Division Leader for Studer Group and is an international speaker, coach, and account leader. In addition, she has published multiple articles in peer-reviewed nursing journals, author of the book Excellence in the Emergency Department: How to Get Results and co-author of the book Advance Your Emergency Department: Leading in a New Era.


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