Patient satisfaction white paper

Emergency Medicine Associates, P.A., P.C.
20010 Century Blvd. #200 Germantown, MD
www.emaonline.com · 240.686.2300
Improving Patient Satisfaction Scores through an Innovative Coaching Program
February 2016
Medicine has not escaped the trend of evaluating the customer experience as a means of
distinction in a competitive marketplace. For the healthcare professions, the customer service bar
is patient satisfaction, most often measured by scores on surveys designed to judge the quality of
a patient’s visit. As healthcare providers and systems are increasingly incentivized to deliver the
highest quality care at the lowest possible cost, organizations are seeking effective solutions to
increasing patient satisfaction scores. This paper discusses an innovative approach adopted by
Emergency Medicine Associates (EMA), PA, PC, which provides staffing to 16 emergency
departments (EDs) and urgent care centers in Virginia, Maryland, Washington, D.C., and West
Virginia. Drawing on more than 40 years of experience, EMA, the largest provider of ED
staffing services in the National Capital Region, has worked in partnership with the Texas-based
consultant ZFactor Group, LLC, to implement a coaching program for providers that contributed
to an 11 percent improvement in the company’s overall patient satisfaction scores from 2008 to
2015.
The evolving role of patient satisfaction in healthcare
Businesses began using customer satisfaction surveys to monitor their service performance in
the early 1980s. Healthcare was not far behind; Notre Dame professors Irwin Press and Rod
Ganey founded Press Ganey and Associates in 1985, creating what is today the largest patient
satisfaction survey vendor in the country. In 2002, the Centers for Medicare and Medicaid
Services (CMS) and partners began developing the Hospital Consumer Assessment of
Healthcare Providers and Systems (HCAHPS), a survey designed to capture patients’ perception
of care following discharge. HCAHPS was implemented in 2006 and hospitals began receiving
financial incentives for participating in the surveys four years later. As part of the Affordable
Care Act, since fiscal year 2013 comparative HCAHPS scores have been a factor in CMS
hospital reimbursement rates. (ACEP, 2011; Siegrist, 2013; Wilson, 2014)
Although the current HCAHPS survey applies only to inpatient care, healthcare
administrators acknowledge the critical role the ED plays as a doorway to the hospital and have
increasingly come to consider patient satisfaction scores as a factor in selecting provider groups
to staff their facilities, notes the American College of Emergency Physicians (2011). CMS is in
the final stages of rolling out an ED-specific version of HCAHPS, which will allow comparison
of EDs nationwide and solidify the connection between ED patient satisfaction and hospital
reimbursements.

The growing importance of the patient satisfaction score has placed increased pressure on
providers to mind their bedside manners and focus on an aspect of care not typically covered in
depth in most medical school curricula. Like most patient satisfaction surveys, EMA’s asks
patients whether the provider was courteous, took the time to listen, communicated clearly, kept
the patient informed about treatment and showed concern for his or her comfort. “Some people
come out of training programs where they haven’t really talked about this before. This is now an
important part of the business of healthcare,” says Tina Latimer, MD, FACEP, EMA’s Chief
Learning Officer and Vice Chair of the ED at Carroll Hospital Center in Westminster, Maryland.
Emergency medicine providers face a particular challenge in satisfying patients, given increased
demands for productivity and the use of wait times as a performance metric for hospitals. In
2014, EMA’s providers spent an average of 15 minutes with each patient and saw approximately
1.5 to two patients per shift hour. Given the brevity of encounters, clinicians must identify ways
to immediately connect with a patient and family when they walk in a room.
In addition to the pressures on their personal performance, providers also must cope with the
fact that many of the influences on patient satisfaction are beyond their control. Hospital
capacity, patient interactions with other staff members and wait times for laboratory or radiology
services are just a few examples. “That is the situation that we live in as physicians,” says Linda
Nordeman, MD, FACEP, the EMA physician who chairs the ED at Washington Adventist
Hospital in Takoma Park, Maryland. “We need to take responsibility for more than just the
medical care that the patient receives. That is a real paradigm shift for many of us, especially
those of us who have been practicing for quite a while.”
Existing methods of improving patient satisfaction scores
Nationwide efforts to improve patient satisfaction scores have led to a number of standard
approaches, many informed by scientific studies:
Mentoring – Seasoned providers with high patient satisfaction scores observe and mentor less
experienced providers, or those achieving lower scores.
Video feedback – A practice videotapes patient interactions – either real or in a simulated
environment – and providers review footage and discuss strategies for improvement.
Scripting – Providers use key phrases or words when interacting with patients to stimulate the
perception of a positive experience. For example, if the survey tool specifically asks whether the
provider showed concern for the patient, the provider might be encouraged to specifically say the
phrase “I am concerned…” during each patient interaction.

Callbacks – Providers conduct post-appointment follow-up calls with a certain number of
patients to make sure their needs have been met and answer any additional questions.
Practices nationwide have reported varying levels of success with each of these approaches.
While many providers embrace scripting, some struggle with feeling insincere. Mentoring and
video feedback can be very effective, but it is sometimes difficult for providers to give a genuine
representation of their bedside manner in the presence of an observer (Robbins, 2015). These
methods are also costly. Building on a program she was involved in at Johns Hopkins University,
Latimer led the development and execution of a simulation-based workshop for EMA providers
with low scores in fall 2013. Participants reported benefiting from the experience, but the
company says logistical challenges prevent this from being a scalable solution for the future.
A common challenge for all of these approaches is a cultural lack of interest in patient
satisfaction scores, notes EMA Director of Patient Satisfaction Peter Paganussi, MD, FACEP.
“None of us likes seeing a report card, especially one that really is subjective,” he says. “The
other thing is, in a way, it’s boring. It’s not like talking about autotransfusion in a trauma patient,
for example.” To combat apathy, Paganussi emphasizes to providers how investing the time to
pursue higher patient satisfaction scores will ultimately make their jobs easier. More satisfied
patients are more likely to comply with care and inspire a work environment with higher morale
(ACEP, 2011). Many healthcare systems and medical groups, including EMA, offer financial
incentives or disincentives based on an employee’s patient satisfaction scores, hoping to
motivate providers to make the necessary investments in altering their patient interactions.
A new approach at EMA
Since its foundation in 1971, EMA has grown to more than 300 full-time physicians and mid-
level providers. The practice has never lost a contract and prides itself on providing a staff that
will improve the quality of any hospital it supports. Consistent with national trends, EMA began
focusing on creating more satisfying experiences for ED patients in 2006, when it appointed a
senior partner to serve as director of patient satisfaction and began tracking patient satisfaction
scores using Press Ganey tools. In 2008, the practice shifted to using its own survey and began
developing a dashboard system and educational sessions with tips on ways to improve scores,
like providing business cards to patients, maintaining eye contact and asking affirming questions
to demonstrate listening. As some providers continued to struggle, EMA considered one-on-one
coaching, an approach that a few practices were trying nationally, typically using high-
performing peers as coaches. “There’s a significant component of patient satisfaction that has to
do with the personality skills that you bring in to the encounter,” says Donald Infeld, MD,
FACEP, President and Chairman of EMA. “Doctors, like everyone, have a wide variety of
different personality characteristics. We have a host of doctors who are innately charming and

very engaging, and then we have a host of people who are very competent clinicians who don’t
naturally have those skills. What we sought in part was to teach certain techniques so that even
those who are less innately gifted in personality interactions can satisfy patients in the clinical
setting.”
Patient Satisfaction Coaching
In 2009, EMA was introduced to LeaderXY Group, LLC, now known as ZFactor Group
(ZFG), LLC, a consulting company whose founder and Chief Executive Officer (CEO), Alan
Goldsberry, had developed a unique coaching platform to help employees meet their
organizations’ goals. Although Goldsberry and his team had no medical background and no
healthcare organizations among their clientele, they surmised that the coaching process, which
focuses on training an individual to be mindful of the emotional quotient in personal encounters,
could be just as effective for healthcare providers as it had been for the variety of business
professionals ZFG had served before.
Goldsberry met with EMA’s executives to identify the practice’s patient satisfaction goals
and design a five-minute online survey to assess a provider’s current understanding of patient
satisfaction and EMA’s scoring process. “The goal is to meet people where they are, in their
current thinking and activities, and encourage them to see what the objectives are within the
organization and what they need to do to reach them,” Goldsberry says. Once a provider who
was struggling with patient satisfaction scores completed the survey, he or she was assigned a
coach and offered a series of sessions and access to an online resource portal tailored for EMA.
ZFG’s typical approach is to design a coaching process and then train select leaders within an
organization to serve as coaches to their peers. But participants quickly found that the
unpredictable schedules of the ED physicians made it difficult to arrange and follow through
with coaching sessions. At EMA’s request, ZFG agreed to provide the coaching services by
phone. Some providers say this strengthened the credibility of the coaching services and
circumvented potential challenges with peer competitiveness. “[The coach] is someone outside
of medicine, which is really important,” says Nordeman, who oversees a staff of 15 providers.
“It’s someone who has developed skills in a different arena, the business arena. I think that
physicians, probably like people in many professions, respond to experts. Alan isn’t telling us
how to work in the emergency department. He’s sharing insights and skills in which he is an
expert.”
Goldsberry based the coaching program on the premise that in addition to trying to correct
known issues, providers would benefit from improved mindfulness during patient interactions. In
an article published in the Journal of the American Medical Association, Ronald Epstein (1999)
describes mindfulness as “the opposite of multitasking,” a tool to help a person increase self-
awareness and social intelligence to understand how they are perceived by others and strengthen

social interactions. “Although mindfulness cannot be taught explicitly, it can be modeled by
mentors and cultivated in learners. As a link between relationship-centered care and evidence-
based medicine, mindfulness should be considered a characteristic of good clinical practice” (p.
833). Over time, providers can develop unconscious competence in this area, allowing them to
automatically size up a patient’s emotional state and the level of effort likely required to meet his
or her emotional needs, similar to how they automatically assess a patient’s physical health
needs.
The ZFG coach conducts three to five phone sessions with the provider, spaced several
weeks apart. The coach begins by asking the provider to walk through an example patient
encounter and then helps him or her identify small tactical adjustments that have been shown to
improve patient satisfaction, such as introducing oneself to each person in the room, always
donning the white coat and sitting rather than standing while talking to the patient. As the
sessions progress, the coach helps the provider evaluate his or her thought process during patient
encounters that were particularly difficult. The provider is assigned homework of assessing how
he or she thinks or feels when first encountering patients in order to identify patterns that could
potentially be problematic. For example, some providers struggle with apathy toward “frequent
flyers” who visit regularly for non-emergencies. Others become inpatient with patients who self-
diagnose or offer too much detail. Some find their interactions are colored by personal
experiences, such as perceived lack of respect based on their gender or stature, or memories of an
overbearing parent that make it difficult to focus when they witness similar relationships
between patients and guardians. By acquiring the skills to recognize their biases, providers are
able to make conscious decisions not to let them affect current patient interactions, Goldsberry
says.
By talking through patient encounters with Goldsberry, Ameet Parikh, DO, Assistant
Director of the Department of Emergency Medicine at Jefferson Medical Center in Ranson, West
Virginia, pinpointed potential areas for improvement in his communication style. “It’s hard to
self-identify some tendencies and nuances in how you treat people, including body language and
verbiage. So this was good coaching,” Parikh says, adding that he is now more self-aware during
encounters and has made adjustments to how he speaks to patients. His patient satisfaction scores
rose about 20 percent from 2013 to 2015.
Latimer elected to take the patient satisfaction coaching in the summer of 2013, looking for
assistance in how to make better connections with concerned parents of pediatric patients.
Goldsberry helped her develop strategies for acknowledging parents’ fears and articulating her
empathy. “I think it’s very rare in any field of employment that you have a timeout where you
talk about your work. I thought it was really meaningful,” Latimer says. “While I felt I had the
tools to talk to patients, it was just really good to identify my core values that drive those
discussions and commit to using evidence-based tools that do make patients have a good
experience.” She now ends every pediatric patient encounter by saying to the parents, “I know

it’s always concerning when you have to bring your child to the emergency department, so I
want to make sure I answer all of your questions, even the ones we haven’t talked about.”
Latimer also found value in ZFG’s hallmark tool: an XY graph that divides patients into four
quadrants based on the intensity of the medical care they will need and the intensity of empathy
and communication. The tool offers providers a framework for categorizing patients in order to
adjust their own expectations about the amount of time and energy an encounter will take, and
employ the acquired strategies to satisfy patients’ emotional needs. Paganussi agrees that this is a
key element to providers’ understanding of patient satisfaction. “The people who need more of
my time are often the ones who have less wrong with them. I will spend 30 minutes – an eternity
in emergency medicine – talking to a patient that I’m not going to order any tests on,” he says.
“If you spend extra time with people, you’ll save time in the end because you don’t have to do
defensive laboratories. When all is said and done, they want to know that you cared, they want to
know that you were there and you went to bat for them.”
One of the most common challenges Goldsberry hears from physicians is frustration over
being accountable for aspects of the healthcare system over which they have no control.
Frustration reduces efficiency, and Goldsberry’s goal is to help providers recognize what they
can and cannot control, and focus on the former. “You look at the overall medical community
and how much change they’ve had to endure in just the last decade and you hear these physicians
talk about how their practice is no longer just clinically focused, they now have to deal with
patient encounters and patient experience,” he says. “In the midst, physicians have had to make
amazing adjustments to how they interact with the patients.”
Despite already having high patient satisfaction scores, Nordeman elected to take the
coaching shortly after joining EMA to learn more about the resources available to her staff and
explore ways that the department as a whole could raise its scores. For her, a major challenge as
©ZFactorGroup,LLC

a new provider at Washington Adventist was using interpreters or telephonic translators to
communicate with the large portion of the hospital’s patient population that does not speak
English. “The patient often does not look at me and because of the time delay I fear I am missing
information or don’t have the ability to steer the conversation in the way that is most
productive,” she says. “It’s frustrating in a number of ways. You lose that connection with the
patient, which is something I really enjoy about my job and I think also is something that
actually improves your patient satisfaction scores.” Goldsberry helped her recognize those
feelings and develop a habit of acknowledging when she goes into an encounter with a patient
who does not speak English that the interaction may take more time than normal and will not
result in the same kind of interpersonal relationship. “Every time I start to feel myself feeling
frustration, I think, ‘Linda, manage your expectations.’ It’s a very simple tool that helps me
every single day,” she says. Nearly all of the providers in Nordeman’s ED have gone through the
training, and scores for the department as a whole increased from 60.5 percent of fives – the
highest score possible on a survey – in 2008 to 72.5 percent of fives in 2015.
Integrating Patient Satisfaction into Clinical Culture
In the first few years of the coaching program, the only providers who utilized it were those
who were required by EMA to do so because their patient satisfaction scores were not meeting
the company’s standards. Many were resistant to the introductory survey and the notion of being
evaluated based on patient satisfaction at all. But between 2008 – the year before the program
began – and 2013, EMA’s overall patient satisfaction score rose by 17 percent. It has fallen
slightly in the past two years, as the company has acquired new contracts to staff EDs that have
historically struggled with patient satisfaction. The increase cannot be attributed exclusively to
the coaching program, but it is one of several aspects of EMA’s patient satisfaction program that
the practice’s leadership recognizes as successful. “Overall, I think most people have found it
valuable as one of the toolkits in assisting them with improving their performance,” says CEO
Jackie Pollock.
More than 90 EMA physicians and physician assistants have participated in the coaching
program. EMA continues to require providers who receive poor patient satisfaction scores to
undergo coaching, but many providers with higher scores self-select to do so because they are
looking for help in overcoming a particular challenge. In some cases, physicians who have
struggled with their scores for years have seen an almost immediate turnaround following the
coaching program. “In the beginning, patient satisfaction is something that we talked about, now
it’s something that’s in most of our DNA,” says Wendy Walker, who has been EMA’s Director
of Human Resources since 2009. “That’s the transition that occurs when you do it well, it just
becomes part of what we do every day.”
Goldsberry, who has transitioned to doing all of the coaching himself as scores have risen
and the number of clients has slowed, has found the physicians to be remarkably adaptable and

able to make significant progress over the course of three or four phone calls. “What really
intrigues me about the physicians is how quickly they can make adjustments given the number of
encounters they have in a day. It’s an opportunity. Most professionals, it could take a week or
longer to have the same number of encounters as a physician has in one shift,” he says. As the
coaching program has gained a positive reputation among EMA providers, Goldsberry and
Walker have both noticed less resistance to coaching referrals. Goldsberry credits EMA for
creating a culture that integrates patient satisfaction into the clinical process.
Despite the many anecdotes of success, Latimer notes that people have different learning
styles and those who are less introspective may struggle to find value with the coaching
approach. Parikh adds that willingness to be coached is a key factor in whether the process is
successful. In addition to coaching, EMA continues to offers scripting and other measures to help
its providers improve patient satisfaction scores, and requires them to do patient callbacks.
A model for the future
In a world where physicians are now accountable for providing patients with faster and more
satisfying service, EMA, in partnership with ZFG, has developed a strategy to better equip
providers to maintain high patient satisfaction scores. Unlike existing peer coaching programs
that focus primarily at the tactical level, EMA’s patient satisfaction coaching program
encourages providers to be more mindful of their own biases when approaching patient
encounters in order to deliver more emotionally satisfying care. Increased self-awareness and the
anecdotal successes reported by many of the providers who have gone through the program have
helped EMA to create a culture within its practice that incorporates patient satisfaction into
clinical care.
In addition to the obvious benefits that the coaching program offers EMA’s patients, the
practice’s ability to maintain high patient satisfaction scores has been good for business. Walker
and Pollock describe multiple cases when hospital administrators have commented upon
awarding a contract to EMA that its strong patient satisfaction score relative to other bidders was
an important factor in their success. “Having outstanding patient satisfaction scores is critical in
our industry,” Pollock says. “When you have a busy emergency department, seeing anywhere
from 30,000 to 80,000 patients a year, you’re touching a lot of the community. If they have a
great experience in the emergency department, they’re likely to recommend that to family and
friends. So administrators feel like patient satisfaction scores are really critical to their success.”
The coaching program has also contributed to employee satisfaction. Several providers
applaud EMA’s effort to offer effective tools to help raise their scores, particularly since the
scores influence compensation levels. Parikh appreciates that by offering the coaching as a
benefit at no cost to the employee, EMA is helping its providers gain important skills that make

them better clinicians and have value beyond their current position. “They’re invested in the
actual person, in human capital,” he says. “It’s nice to see that from a company.” Nordeman,
who has been in practice for 26 years and involved in many patient satisfaction initiatives, says
she has yet to encounter a program like this. “I feel like EMA has really come up with an
interesting way of addressing this issue,” she says. “It’s thinking outside of the box, which I
really like. It’s being creative and investing in something that will help us.”
References
American College of Emergency Physicians Emergency Medicine Practice Committee. (June
2011). Patient Satisfaction: Emergency Department Patient Satisfaction Surveys.
Retrieved from http://www.acep.org/patientsatisfaction/.
Centers for Medicare and Medicaid Services. (2015). Emergency Department Patient
Experiences with Care (EDPEC) Survey. Retrieved from https://www.cms.gov/Research-
Statistics-Data-and-Systems/Research/CAHPS/ed.html.
Epstein, R. (September 1, 1999). Mindful Practice. Journal of the American Medical
Association, 282, 9, 833-839. doi: 10.1001/jama.282.9.833.
Goleman, D., & Boyatzis, R. (September 2008). Social Intelligence and the Biology of
Leadership. Harvard Business Review.
Robbins, A. (April 17, 2015). The Problem with Satisfied Patients. The Atlantic. Retrieved from
http://www.theatlantic.com/health/archive/2015/04/the-problem-with-satisfied-
patients/390684/.
Siegrist, R. (November 2013). Patient Satisfaction: History, Myths, and Misperceptions. Virtual
Mentor, 15, 982-987. Retrieved from http://journalofethics.ama-assn.org/2013/11/mhst1-
1311.html.
Wilson, J. (February 4, 2014). Why Patient Satisfaction Is an Uphill Climb. Medical Scribe
Journal. Retrieved from http://scribeamerica.com/blog/patient-satisfaction-uphill-climb/.

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