Objectives The goal of this study was to describe and analyse interventions performed in the emergency department (ED) of an Italian hospital with the aim of humanising the patient care pathway. The actions taken are described and the changes analysed to determine whether they resulted in an increased level of patient satisfaction.
Methods An observational study was conducted between October 2010 and March 2011. The data were collected via a telephone questionnaire administered to patients who were admitted to the ED before and after humanisation interventions. The respondents were questioned about their general condition and their level of satisfaction.
Results The study population included 297 patients (158 before and 139 after the interventions). The highest overall patient satisfaction after the interventions was highly correlated with the humanisation interventions and not with other factors such as gender, age, educational level or the severity code triage. Specifically, in patients who went to the ED after the changes had been made, there was a greater level of satisfaction regarding comfort in the waiting room, waiting time for the first visit and the privacy experienced during the triage.
Conclusion The results demonstrate that the interventions implemented in this study, designed to humanise the ED, improved overall patient satisfaction. Interventions may be taken to reduce the depersonalisation of patients in the emergency room.
- patient satisfaction
- emergency department
- emergency department management
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In recent years the levels of medical assistance and hospital care have been enhanced as a result of technological performance improvements in diagnostics and treatment. However, care pathway fragmentation, the increase in medical specialists and the lack (at least in Italy) of a ‘care manager’ have led to the depersonalisation of patients. These issues are greater in the emergency department (ED) due to the services provided and the greatest risk of depersonalisation or ‘dehumanisation’.1
In the current global financial crisis, quality is a critical factor for the survival of healthcare facilities. Although every effort is aimed at reducing costs and increasing the number of procedures performed, the risk of losing the centrality of the patient as a ‘human’ is high.
Since the 1990s, research interest in clinical practice quality assessment has continuously grown.2 ,3 The concept of ‘customer satisfaction’ (or ‘patient satisfaction’) must be placed in the context of overall quality improvement, and it is a serious issue in emergency medicine, as shown in the literature,4–8 which emphasises the difficulty of accurately measuring patient satisfaction because it may be influenced by perception, the interpretation of events or clinical conditions.1
Quality and satisfaction are strictly related to the concept of humanisation of healthcare, which involves medical services for diagnostics and treatment and also the other aspects of the care process such as logistics, environment, food, waiting times and communication.9 However, little attention has been given to the concept of ‘humanisation’ in international medical publications because the literature is more focused only on the concept of ‘patient satisfaction’.
Few studies have compared the level of satisfaction perceived by patients before and after an ED humanisation intervention,10 ,11 and most of the studies have focused on a specific intervention. For example, Kologlu et al12 and Krishel et al13 reported the results of an improvement intervention (ie, the distribution of an information form), Corbett et al studied an informational videotape14 and George et al used an informal prioritisation process for waiting times.15
Other studies have suggested that patients' overall perception of care appeared to be associated with the humanistic attitude and technical competencies of the professionals, the perceived waiting time, the perceived total time spent in the ED and the amount of information provided to patients.7 ,11 ,16 However, there are other factors associated with patient satisfaction that are difficult to evaluate, such as privacy, cleanliness, safety and low noise levels in patient rooms.4
The aim of this paper is to describe and evaluate the effectiveness of interventions designed to improve the patient experience in the ED.
An observational longitudinal before and after study was conducted to evaluate patient satisfaction levels19 after a series of structural and organisational changes were applied in an ED. The study was authorised by the Health Department staff and carried out from October 2010 to March 2011 in the ED of Rivoli Hospital located in the Turin urban area.
The study population included all patients who were admitted to the emergency room during October, November and December 2010 (before the ‘humanisation’ interventions) as well as during January, February and March 2011 (after the ‘humanisation’ interventions). To select patients for this study we chose 2 days of the week and contacted all of the patients who had been admitted to the ED during those specific days. Saturday and Wednesday were chosen to represent the holidays and work days, respectively. Patients admitted with a triage ‘Red Code’ due to the admission details that characterised these patients, such as the urgency of their condition, were excluded.
Patients were contacted by telephone 2 weeks after visiting the ED. Participation in the interview, which was conducted by medical professionals,5 ,20 was voluntary after the patient was given a thorough explanation of the study and gave consent. Before the interview the patient was informed about the opportunity to refuse or stop the interview at any time. Clinical data on the patient's condition or information about prescribed therapies or diagnostics performed in the ED were not collected.
Ethical approval is not necessary in Italy for customer satisfaction surveys when this kind of study is conducted after authorisation by the hospital management and all the data are processed anonymously. The personal data of patients collected from the clinical record were therefore used only to identify the patients called, but were not inserted in the interview database in order to guarantee anonymity.
The questionnaire was first tested in a pilot study on 30 individuals who were excluded from the final study. The questionnaire was designed to measure overall patient satisfaction and to assess, at an individual level, the different aspects of satisfaction. We calculated the average satisfaction values for the abovementioned categories—namely, first impression of the ED, adequacy of signage, comfort level in the waiting room, presence and availability of staff, waiting time for the first visit, clarity of information received, volunteer activities, discretion during triage and overall opinion. Using a 10-point scale, the average values were calculated to assess the satisfaction trends before and after the intervention.
In addition, patient demographic information (age, sex and educational level) and other information (admission time to the ED, triage code and previous ED admissions) were included.
The study population was then divided into two subgroups: the first group (‘Before’) included patients who were admitted to the ED before implementation of the changes described above and the second group (‘After’) consisted of those who went to the ED after the changes had been implemented. The inclusion criteria ensured the comparability of the groups.
In order to humanise the care pathway, we studied and performed structural and organisational changes to improve the ED area. The changes that were implemented are described in table 1.
A descriptive analysis of the study population, including patient demographic information (age, sex, and educational level) and other information (admission time to the ED, triage code, and previous ED admissions) was performed to verify the comparability of the two groups.
Analysis of data
Multinomial logistic regression was performed to identify the potential predictors of the differences in the distribution among the three classes of patient satisfaction (poor, medium and high). We developed several bivariate models and identified variables that were significantly associated with the outcome at a 5% level. These variables were included in the multinomial regression analysis. In the final model the variables were group, age class, gender and education. The final model estimates for each of the variables were adjusted by controlling for the other variables. A two-tailed p value of 0.05 was considered significant for all analyses, which were carried out using Stata V.11.
The source population was made up of all persons attending the ED on the days established. It was necessary to exclude 52% of the subjects due to lack of contact information or because they did not answer the telephone on two occasions. The study population was composed of 576 individuals who were invited to participate in the interview. The compliance rate was 53%. The final sample therefore comprised 297 subjects (49.5% men) of mean±SD age 48.6±13.9 years. The details and descriptive characteristics of the participants stratified by group (‘Before’ and ‘After’) are summarised in table 2.
We initially estimated the range of the average satisfaction level by group (figure 1). The perceived satisfaction level was slightly greater in the ‘After’ group for the following categories: comfort level in the waiting room, waiting time for the first visit, clarity of the information received, discretion during triage and overall opinion. In contrast, the overall average rating in the ‘After’ group was slightly lower for first impression of the ED, adequacy of signage and presence and availability of staff.
In agreement with other studies,24 the individual scores were grouped into three levels:
‘poor’ satisfaction (grades 1–4)
‘fair’ satisfaction (grades 5–7)
‘good’ satisfaction (grades 8–10)
The relationship between the level of perceived patient satisfaction and the humanisation intervention is summarised in table 3.
We considered the respondents' level of satisfaction for each category and compared the responses of the two groups. The satisfaction ratings of the two patient groups differed in the following categories: first impression of the ED (p<0.001), adequacy of signage (p=0.019), presence and availability of the staff (p<0.001), waiting time for the first visit (p<0.001), discretion during triage (p=0.03) and overall opinion (p<0.001).
Patients in the ‘After’ group showed greater satisfaction in the following categories: waiting time for the first visit, clarity of information received, discretion during triage and overall opinion of the ED. In contrast, the patients in the ‘After’ group appeared to perceive a lower satisfaction in the following categories: first impression of the ED, adequacy of signage, and presence and availability of the staff. Of the patients admitted before the structural and organisational changes were implemented, 60.1% reported a fair first impression of the ED and 32.3% had a good opinion. In the ‘After’ group, 67.6% had a fair opinion of the ED and only 9.4% had a good first impression of the ED (p<0.001).
In the ‘Before’ group, 7.6% of patients had a negative opinion regarding the adequacy of the signage, and this percentage rose to 17.3% in the ‘After’ group (p=0.019). Similar results were found for the presence and availability of the staff (fair/good evaluations given by 92.4% of patients in the ‘Before’ group and 87% of patients in the ‘After’ group; p<0.001). We did not find any statistical differences between the level of comfort in the waiting room (p=0.46) and the clarity of information received (p=0.57).
We specifically analysed these data using a multivariate analysis to investigate which factors affected the overall patient opinion using overall good opinion as the dependent variable. Table 4 shows that the categories significantly associated with an overall good opinion of the ED (p<0.05) were level of comfort in the waiting room, waiting time for the first visit and discretion during triage. All of these variables had a positive effect on patient satisfaction while the first impression of the ED had a negative effect.
A multinomial logistic regression was performed to identify the potential predictors of the differences in the score distributions among the three classes of patient satisfaction. Table 5 shows that the ‘After’ group had a greater level of satisfaction than the ‘Before’ group regarding overall opinion of the ED. In particular, by comparing the overall opinion scores in the two groups, we found that the ‘After’ group had a higher probability of having an opinion of ‘fair’ (regression coefficient 1.50, p=0.001) or ‘good’ (regression coefficient 1.17 and p=0.031) compared with the probability of an overall opinion of ‘poor’ (table 5).
The results demonstrate that the interventions implemented in this study, designed to humanise the ED, improved overall patient satisfaction.
This is the first study conducted in Italy to describe a variety of significant structural and organisational changes implemented in the ED and to investigate how these changes are perceived by patients. The international literature is primarily focused on ‘patient satisfaction’, but a small number of recent studies have described and studied structural and organisational changes in the ED. Moreover, these studies have referred to individual actions (ie, structural or organisational)13 and hardly investigated the level of satisfaction perceived by the users in relation to these action.14 The active approach of this study, which included a practice intervention, in combination with the evaluation of the consequences of the interventions is a major strength of this study.
To choose the best interventions in the emergency room we performed a literature review and identified the most critical areas for ‘depersonalisation’, patient satisfaction and hospital organisation. Based on other published studies, we performed this study in the ED.
In accordance with other publications, telephone interviews were performed in this study.20 During the waiting time in the ED, responses could have been affected by the user's state of mind or their health condition, particularly if the patient was unable to have an unbiased perspective. However, the telephone survey method resulted in a lower response rate than face-to-face interviews but a higher rate than email interviews.5
The main result of this study is an increased level of overall satisfaction after the changes in the ED. The elements found to affect overall patient satisfaction most were the level of comfort in the waiting room, waiting time for the first visit and discretion during triage. In agreement with other studies, we found that the perceived waiting time is a significant factor in satisfaction.5 ,6 Previous studies showed that patients who receive information concerning their medical care and the reasons for waiting reported much higher levels of satisfaction than others who do not receive this information.16 The findings of the present study demonstrate that discretion during triage is important in patient satisfaction, but not the clarity of information received.
We found a statistically significant decrease in the level of satisfaction from the ‘Before’ group to the ‘After’ group with regard to the first impression of the ED (p<0.001), the adequacy of signage (p=0.019) and the presence and availability of staff (p<0.001). The first impression of the ED and adequacy of signage can be explained by considering that the interventions mentioned in this paper are part of the overall hospital restructuring. Therefore, the ‘After’ group visited the hospital when different areas were incomplete or undergoing construction.
With regard to the presence and availability of staff, it may be appropriate to separate ‘presence’ from ‘availability’ in any related analyses because the ‘presence/number of workers’ is an objective parameter whereas the ‘availability’ is a personal assessment. This result should therefore be reassessed with a larger study population and a greater number of observation days.
It is clear from these results that the availability of staff and communication are two key aspects for the patient. For this reason, future efforts to improve the patient experience in the ED should provide training for staff to improve the communication and management of human relationships.
Some weaknesses of the study have been identified. In particular, the actual waiting time for each patient, the reason for patient admission8 and the presence of pain were not evaluated. This information may affect the patient satisfaction level, as reported by other authors.10 Further limitations of the study are the small sample size and the lack of staff training programmes concerning the ‘humanisation’ concept.
We conclude that, for the first time, our study demonstrates that interventions designed to humanise the ED have a real and measurable effectiveness and increase overall patient satisfaction.
Contributors EL: analysis and interpretation of the data/drafting of the manuscript. DM: study concept and design/critical revision of the manuscript for important intellectual content. MG: analysis and interpretation of the data/drafting of the manuscript. RS: administrative, technical, or material support/study supervision. AP: administrative, technical or material support/study supervision. BB: administrative, technical or material support/study supervision. RP: acquisition of the data. FB: statistical expertise. RS: study concept and design/critical revision of the manuscript for important intellectual content.
Competing interests None.
Patient consent Consent was obtained during telephone interview.
Ethics approval Ethics approval was provided by Health Department staff.
Provenance and peer review Not commissioned; externally peer reviewed.
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