SASKATCHEWAN

HEALTH QUALITY
COUNCIL

PATIENTS' EXPERIENCES WITH EMERGENCY CARE IN SASKATCHEWAN HOSPITALS

KEY MESSAGES
Patients experiences suggest there is room for improvement in emergency department care. Less than a quarter (21.6%) of patients rated their overall care experience as excellent. Although 82% of patients rated their care as good, very good, or excellent, the excellent rating alone is a more useful measure to follow over time when the goal is exceptional and truly patient-centred care. Patients call for more courteous interactions and want improved information sharing during their emergency care experiences. About a quarter of patients rated the courtesy of emergency department staff as excellent. Just over half said they were involved as much as they wanted to be in making decisions about their care and treatment. Patients want easy access to appropriate care when they need it. In explaining why they chose to go to the emergency department, about half of the patients said there were no other options available. About 30% of patients said they went to the emergency department because they had an appointment or they were told to go to the emergency department for follow-up care.

WHY PATIENTS VOICES MATTER

The ultimate measure by which to judge the quality of a medical effort is whether it helps patients (and their families) as they see it. Anything done in health care that does not help a patient or family is, by definition, waste, whether or not the professions and their associations traditionally hallow it.
-Dr. Don Berwick, Administrator of the Centers for Medicare & Medicaid Services in the United States, and former President and Chief Executive Officer of the Institute for Healthcare Improvement (IHI).

In high performing health care systems around the world, the patients perspective and satisfaction with care are emphasized as valid outcome measures of quality. The patient is becoming widely recognized as a reliable and important source of information about quality of care. Measuring patient experience and satisfaction provides a voice for patients. Completing a survey is one way for patients to participate more in their care experience, which is linked with higher likelihood of following prescribed treatments and discharge instructions, higher employee satisfaction, and 1,2 improved morale and staff retention. Since 2007, the Health Quality Council and Saskatchewans regional health authorities (RHAs) have collaborated to conduct a provincial and continuous acute care patient experience survey. In response to the Patient First Review, which highlighted the need to listen to the patient voice, the Health Quality Council asked the RHAs where else they would like to implement patient experience surveying and they suggested emergency departments. Therefore, the first emergency department patient experience survey was conducted between January 18, 2011 and March 14, 2011 in 14 of the most active emergency departments in the province.

This emergency department patient experience survey is the first time patients voices in this area of care have been captured across the province. The survey results provide standardized and comparable data on the current state of patients experiences with emergency care. The survey serves as a baseline measurement for the implementation of new emergency department improvement initiatives; and, provides staff with an opportunity to compare their performance with other hospitals in the province, and learn from each other to improve patients experiences.

1 Browne K, Roseman D, Shaller D, Edgman-Levitan S. Measuring Patient Experience As a Strategy for Improving Primary Care. Health Affairs. May 2010; (29)5: 921-925. 2 Aligning Forces for Quality. Good for Health, Good for Business: The Case for Measuring Patient Experience of Care. Washington, DC. Robert Wood Johnson Foundation; 2010.

Percent of patients who reported excellent overall care

The care I received was prompt and efficient. The front desk was courteous and prompt, nurses knew what to do, the lab personnel and X-ray personnel were very efficient and quick. The doctor kept me and my husband informed as to what was happening and what to expect. Very good care exceptional.

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WHAT DID PATIENTS SAY ABOUT PATIENT- AND FAMILY-CENTRED CARE?

The doctor who attended to me was very busy, and had to be reminded to order an Xray for me. He was unable to answer my questions. The doctor said (and I quote) this is not easily explained. He must have thought I was incapable of understanding, so why bother explaining.
Citizens of Saskatchewan, through the Patient First Review, have called for a health system that is more patient- and family-centred. What is patientand family-centred care? It means ensuring patients feel respected and that their dignity is valued at all points during their care; sharing information with patients and families so they can participate in their own care and decision-making; encouraging patients and families to participate in their care at the level they choose; bridging cultural differences to build effective relationships with patients; and, About half (52%) were involved as much as they wanted to be in decisions about their care and treatment. Information sharing? When patients had important questions to ask, 57% of patients always got answers from a doctor that they could understand. When patients had important questions to ask, 47% of patients always got answers from a nurse that they could understand. 45% said the possible causes of their problem were completely explained in a way that they could understand. Bridging cultural differences? Patients who identified themselves as being of First Nations, Indian, Mtis, or Inuit descent consistently reported significantly worse emergency department experiences than those who did not identify themselves as being of First Nations, Indian, Mtis, or Inuit descent. Patient safety practices? The majority (89%) of patients said they were asked if they had any allergies. 73% reported their identity was confirmed by staff before receiving medications, treatments, or tests.

Was in the city of [name], the service there was excellent. I am from another small city, where they are not so kind and courteous to me as a First Nations woman, when I take myself to the ED. Not so much the service but the unkind words.

authentically collaborating with patients and families to improve our health care system. What did patients say about Courtesy of staff? 3 Approximately 1 out of 3 (35%) said all staff introduced themselves during their first interaction. About 1 out of 4 (26%) rated courtesy of the emergency department staff as excellent. Dignity, respect, and privacy? About 3 out of 4 (74%) were always treated with dignity and respect by hospital staff. Almost 60% definitely had enough say about their care. Almost 70% always had enough privacy during their emergency department visit.

3 In the survey, several questions asked patients about their interactions with hospital staff. Patients responses to these questions reflect on

their experiences with those they thought of as part of the hospital staff, most likely including nurses, doctors, other care providers and support personnel.

What matters in patients overall rating of care?*

I was surprised how quickly I was assessed and my surgery done which took a lot of pressure off of me and my family. My girls (adults) were taken care of very well and everything explained to them also as well as providing a place for them to wait for me. Even the parking attendant helped my daughter out with the 'cash machine' so she could move her car into another lot. We were all pleased with our experience in spite of the serious nature of my condition.

Higher impact on overall rating of care

I found the courtesy of the emergency department staff to be excellent (6.0X)

The explanation I was given about my care was excellent (5.0X)

The doctors and nurses worked together really well (5.0X)

The hospital staff always treated me with dignity and respect (3.0X)

I definitely had enough say about my care (1.7X)

I always felt that I had enough privacy during my emergency department visit (1.6X)

I was told what danger signals about my illness or injury to watch out for when I got home (1.5X)

Overall, the care I received was excellent

* Bar height reflects strength of relationship with the overall rating of care. For example, patients who rated the courtesy of the emergency department staff as excellent are six times more likely to rate their overall care in the ED as excellent. This figure presents the highest odd ratios from logistic regression results. Therefore, the factors presented here are the ones that have the strongest relationships with the overall rating of care in emergency departments.

The patient was my daughter and I have found the nurses, doctors or in general most medical staff do not listen to the mother's concerns. They brush us off as if we do not know anything, or have not tried anything to rectify the problem on our own. I don't run to the doctor for every little scratch ...

What can we do differently? In June 2011, the Saskatchewan Ministry of Health articulated a vision of how Saskatchewan might achieve a health system that is truly patient- and family-centred (http://www.health.gov.sk.ca/ patient-centred). Since the release of the report, a province-wide committee has been formed to translate the vision into action. Health regions are currently identifying best practices and testing strategies that will improve patients experiences with care. For example, Cypress Health Region is in the process of testing a communication tool called AIDET - that focuses on five fundamental concepts: Acknowledge that the patient is important; Introduce yourself and your role; Duration - manage expectations about time; Explain purpose of treatment, possible side effects, answer any questions; and, Thank-you to patients.

What other ideas can we try? Providing communication workshops and customer service training to staff. Providing cultural competence training to staff. Scripting patient communications. For example, acknowledging patients when they arrive, using patients names, making eye contact, asking and carefully listening to answers. Asking patients to restate and recall the information that was shared with them. Developing campaigns to remind staff to be courteous and keep a positive attitude. Providing private examination rooms or pulling curtains to enhance privacy. Having volunteer greeters provide information and comfort services. Telling patients in advance what to expect and when. For example, offer patients and families brochures to inform them about normal wait times, the order in which patients are seen, etc.
(For further information see Listening for Excellence in Patient-Centred Care, NRC Picker and Ontario Hospital Association 2010.)

WHAT DID PATIENTS SAY ABOUT APPROPRIATE AND SEAMLESS CARE?

Emergency was used as a meeting place for a visit with specialist after office hours. It took a very long time before I saw the doctor then he left and it was a long time till he came back and a long time before medicine was administered.
In 2009, Saskatchewan citizens, through the Patient First Review, called for a health system that provides easy access to appropriate care. The report pointed out that emergency rooms are serious pressure points in the system. To alleviate the pressure currently experienced in emergency departments, alternative options for ensuring patients needs are met appropriately should be explored. What did patients say about Why they chose to go to the emergency department? Just over half (54%) said it was clearly an emergency. Almost half (44%) said there were no other options available. Patients who visited a regional emergency facility (51%) or district emergency facility (54%) were more likely than those who visited a provincial emergency facility (34%) to say there were no other options available. 1 out of 20 (4%) said they use the emergency department for all their health concerns. Wait times? About 40% of patients said they waited less than 30 minutes before they were examined by a doctor, while 20% reported waiting more than 2 hours. Only about 7 out of 10 patients (68%) said they talked to a nurse about their illness or injury within 15 minutes of their arrival to the emergency department. Availability of services? Only 16% rated the availability of their nurses as excellent. About 60% said they completely got all the services needed while they were in the emergency department. Being informed about delays? More than half (60%) of patients were not kept informed about delays while they were waiting to be seen. About half (46%) were not made aware that patients are seen in order of severity and not according to actual arrival time.

What matters in patients overall rating of care?

Higher impact on overall rating of care

I went to Emergency because there is no walk-in clinic in town. I strongly feel that a walk-in clinic would be a huge benefit to the community and would dramatically reduce the number of unnecessary visits to the emergency.

The availability of nurses was excellent (8.8X)

I completely received all the services I needed (3.5X)

The amount of time I spent in the emergency department was excellent (2.8X)

Overall, the care I received was excellent

* Bar height reflects strength of relationship with the overall rating of care. For example, patients who rated the availability of nurses as excellent are 8.8 times more likely to rate their overall care in the ED as excellent. This figure presents the highest odd ratios from logistic regression results. Therefore, the factors presented here are the ones that have the strongest relationships with the overall rating of care in emergency departments.

The waiting times are out of control. Whether the illness is very serious, or somewhat serious people should not have to wait more than 2 hours before they even speak to a doctor.

What can we do differently? In response to the Patient First Review, the Ministry of Health invited patients and health and community leaders to share their ideas for redesigned primary health care service delivery that supports patient- and family-centred care. A draft framework is being developed to guide coming changes, and to prepare the province to implement health delivery solutions that are tailored to meet the varying needs of Saskatchewan 5 communities. While primary care redesign addresses wait times and providing appropriate services to meet the needs of communities, it is important to make immediate process improvements in emergency departments to provide better access to emergency services and improve patients experiences.

What ideas can we try? Effectively communicating with patients to keep them informed about expected wait times by - giving estimates for waiting times, and providing visual cues; - explaining the order of seeing patients; and, - informing patients about reason for delays. Effectively communicating with patients to understand and alleviate their anxiety. Effectively managing patients pain. Supplying TVs, computer plug-ins, telephones, and magazines in waiting rooms. Encouraging patients to have friends and family accompany them during their emergency department visit.
(For further information, see Institute for Healthcare Improvement 2011 and Ontario Hospital Association 2010.)

5 The framework is expected to be ready in 2012 and will be available at http://www.health.gov.sk.ca/primary-health-care

HOW DO SASKATCHEWAN SCORES COMPARE WITH THE AVERAGE AMONG ONTARIO AND BRITISH COLUMBIA EMERGENCY DEPARTMENTS?

Indicator 1

Saskatchewan 2, 3 (%) (Jan 18 Mar 14, 2011) 82.0* 67.9 59.2* 57.9* 59.2* 62.2 75.1* 88.0* 69.3*

Average among Ontario and BC EDs (%) (Jan Dec 2010) 85.5 67.8 64.3 63.9 64.3 64.1 77.9 90.3 73.8

The waiting times are awfully ridiculous. I don't really go to the emergency department if I have other choices. Usual waiting time is at least 2 hrs - 4 hrs.

Overall Quality of ED Care Access and Coordination Continuity and Transition Emotional Support Information and Education Physical Comfort Respect for Patient Preferences Courtesy Overall Impressions

* Saskatchewan indicator scores that are statistically significantly lower than the average among Ontario and BC emergency departments. 1 Only unscheduled emergency department visits are reported. 2 Saskatchewan scores presented here are unweighted. 3 Both Saskatchewan scores and Canadian average are reported here using National Research Corporations (NRCs) methodology. In Saskatchewan, we report only the top box scores (those who rated their overall care experience as excellent) for the indicators because evidence has shown that patient satisfaction scores are consistently skewed to the upper end of the scale. So, in order to obtain a true reading of exceptional care, the health system must focus on the proportion of patients who select the top box the highest possible score as their response. NRC, on the other hand, reports the combined score of good, very good, and excellent response options and that is what is displayed in the chart above.

Saskatchewan, Ontario, and British Columbia have all surveyed emergency department patients using the same survey tool, which allows a comparison of survey results in these provinces. When compared with the average from Ontario and BC hospitals, patients experience scores for emergency department care in Saskatchewan are lower in all aspects of quality, except access and coordination and physical comfort. These differences emphasize the need for continuous improvement efforts in our provinces emergency departments.

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IMPROVING CARE EXPERIENCES BY LISTENING TO PATIENTS VOICES

I understand through this survey you will be working towards establishing a better work place and job design, which is why I have taken extra time to make additional comments. I have taken this survey very seriously in hopes of a better facility.
It is very important to listen to patients voices through multiple approaches. While the provincial patient experience survey provides a high level picture of the current state, it is important to support this information with other methods such as patient interviews, focus groups, and/or patient shadowing, to gather more actionable and realtime patient feedback. Capturing patient experiences at the point of care has the advantage of helping health care staff and organizations understand what matters to patients soon after receiving care and treatment; allowing care teams to better understand the factors that are generating adverse experiences for patients, and to come up with ideas for changes that will result in improvements; supporting prompt, small tests of change aimed at improving care that better responds to patients needs; and, establishing continuous feedback mechanisms at different levels of the system (i.e., provincial, organizational, and at point of care) which is crucial for monitoring whether gains are being sustained over time and ensuring continuous improvement. Patients share their experiences partly because they want to make care better for everyone. Their involvement in this way can raise expectations and hopes for change in the system. Patient feedback also provides great motivation and commitment for health care providers to change. A challenge health care teams face, however, is how to use the patient voice to prioritize changes, and decide where to start making improvements. This report highlights some aspects of patients experience as potential priority areas since they have strong links with patients rating of their overall care experiences. However, it is also important to point out that there is no silver bullet for improving patients care experiences, simply because patient experience is multi-faceted; it is the sum of all interactions the patient has with hospital staff. Therefore, it is very important to focus on one-to-one interactions and building relationships with patients and families at every step of the way. The Health Quality Council will be working with interested regional health authorities to interpret their individual facility level results. Regions have committed to using the information gained from this survey for learning and improvement regarding patients experiences in the emergency department. We will also continue to partner with the health system to ensure that patients voices are represented across the continuum of care.

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HOW DID WE ASSESS PATIENTS EXPERIENCES?

Constant monitoring and evaluations need to be put in place. It's about time a survey like this has come out. Hopefully, it is put to good use ...
The Health Quality Council (HQC), in collaboration with regional health authorities, conducted the province-wide emergency department patient experience survey in Saskatchewan between January and March 2011. Survey packages were mailed to a randomly selected sample of 27,361 patients discharged from the participating 14 emergency departments. Patients were excluded from the sample if: they did not have a fixed mailing address; opted out by phoning HQC; or, lived outside Canada. Patients between 12 and 16 years of age were excluded for reasons of privacy, and newborns were excluded since their mothers were included in the survey sample. Results presented in supplementary tables are based on the experiences of 6,255 patients who completed this survey. This report reflects the experiences of 4,132 patients who did not have an appointment for their emergency department visit. The survey also has some limitations. Emergency department patient experience surveys in general have lower response rates than patient experience surveys conducted in other care settings. Our survey in Saskatchewan was no exception; 23% of patients who received the emergency department patient experience survey completed and returned 6 it. Given the low survey response rates and the fact that experiences of some patient groups (for example, homeless patients or patients with mental illnesses) are very difficult to capture through survey methodology, it is important that other methods for eliciting patient voice (such as interviews, focus groups, or feedback received by quality of care coordinators/client service representatives) are used in conjunction with patient experience surveys.

Response rates are 27.7% in BC, 25.6% in ON and 23% in SK.

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For an overview of survey results, including those for Saskatchewan as a whole and for each facility, visit www.qualityinsight.ca. The web-based reporting tool, Quality Insight, is designed to give everyone public, providers, managers, and leaders the information they need to support quality improvement work to make our health care system better and safer for Saskatchewan residents. For detailed tables that outline responses to each question by facility, background information on the survey process, and a copy of the survey itself, visit www.hqc.sk.ca and choose Improving Quality>QI Projects>Patients experiences with emergency department care.

Acknowledgments
HQC thanks the patients who completed an emergency department patient experience survey; your participation is greatly appreciated. We also thank: hospital staff for making patients aware of the survey; health region staff for their assistance with survey implementation; and, the Emergency Department Advisory Working Group for their time and expertise.

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Health Quality Council Atrium Building, Innovation Place 241 - 111 Research Drive Saskatoon, SK S7N 3R2 www.hqc.sk.ca

Recommended citation format: O Sari, N Sidhu, and N Wohlgemuth Patients experiences with emergency care in Saskatchewan hospitals Saskatoon: Health Quality Council November 2011 ISBN 13-978-1-897155-54-7