Surveys Improve the Patient Experience

EMS has long been known for monitoring performances such as response times, return of spontaneous circulation (ROSC) rates, on-scene times and more. These are important performance measures that can lead to improved patient outcomes. 

Medical excellence has always been a priority for EMS. However, it’s no longer enough to know that you arrived at the patient’s side quickly, provided exceptional medical care and possibly saved their life. 
Patient experience is now becoming just as important. Medicare reimbursement and higher consumer expectations are both contributing factors to patient experience playing a larger role in the EMS industry.

Patient Perception

Many patients will only call on EMS once in their lifetime, so their first impression will be their lasting impression of the service an agency provides. Although patients often don’t have a choice of which EMS provider responds to their emergency, EMS agencies must still treat them as if they do and provide the best possible experience.

The patient experience goes beyond addressing a patient’s medical condition. For example, Paramedics Plus received a complaint from a patient who claimed a crew had ruined her favorite nightgown. Its clinical services department looked into the call and found the crew had cut her gown as they were treating her for cardiac arrest. It wasn’t enough that the medics saved her life—she wanted the company to replace her gown. 

This may be a dramatic example of a patient with high customer service expectations, but keep in mind that a patient/customer who is dissatisfied with an experience will tell anywhere from 9–15 people about it.¹ 
Patient perception has a real impact on EMS providers’ reputations, morale and value. But EMS providers don’t know what patients are saying if they don’t ask. Surveys can help bridge the perception gap between what EMS personnel think is happening and what the patient perceives and experiences.

Patient perception and feedback about the EMS experience should be addressed in agencies’ patient care strategies just as operational efficiency strategies are. 

Feedback to Show Value

EMS is under more scrutiny and pressure than ever to demonstrate the value it contributes to the health and well-being of communities. Patient perceptions of EMS experiences may be a good metric to use to show value. 

This perceived value in patient care may someday become the basis for the payments EMS agencies receive from Medicare. Payment structures are anticipated to shift from fee-for-service to value-based reimbursement models, much like the Centers for Medicare & Medicaid Services (CMS) introduced to hospitals in 2010.

Under the Hospital Value-Based Purchasing (VBP) Program, Medicare provides incentive payments based on performance in four key domains: patient- and caregiver-centered experience of care; safety; clinical care; and efficiency and cost reduction.

Medicare puts an additional emphasis on the experience of care, which is weighted 25%. Adding patient experience feedback and input to EMS agencies’ strategic plans can help agencies get ahead of Medicare’s potential mandates.² 

Implementing Surveys

The survey process is just as important as the decision to implement surveys, and there are some important things to consider when conducting patient experience surveys.

Questions—Providers should ask questions related to what patients want or expect from EMS. Paramedics Plus’ questions address themes around arriving quickly, managing pain or discomfort, communication with the patient and family, and the level of compassion patients receive from EMS personnel.

Agencies can develop their own unique sets of questions that address themes important to their communities or research common survey questions used in the EMS industry, which would allow comparison of their results to those of others.

Methods—Surveys can be conducted through direct mail, websites or telephone. Agencies should consider the desired number of responses, cost and validity in selecting a method to use. 

Paramedics Plus performed paper surveys through direct mail until 2015. Surveys were sent to a percentage of randomly selected patients with a self-addressed stamped envelope. Only 17.5% of surveyed patients completed the survey. The small sample size may not have been an accurate reflection of all patients’ experiences, so we explored other methods that would produce a larger sample size and more accurate reflection. 

Paramedics Plus considered conducting online surveys; these are a widely used method due to their minimal cost, quick access to feedback data and respondent convenience. However, people who don’t have access to a computer or the Internet, such as elderly patients or people who live in remote areas, would be excluded from participating. Other disadvantages of this method are the difficulty of open-ended questions and low return rates.³ 

Telephone surveys were also considered. These have a high return rate and present an opportunity to gain more insight into patients’ experiences. Trained interviewers can delve into respondents’ answers, but this is often the most costly and time-consuming method of surveying. 

Weighing the pros and cons of these survey methods, Paramedics Plus initiated telephone interviews primarily because of their high response rate. Since implementing telephone surveys in 2015, we are receiving feedback more quickly and attaining a much higher return rate, meaning a higher percentage of patients complete the survey.

Outsourcing—Some EMS agencies choose to perform surveys internally, hoping to keep costs down and maintain control; however, outsourcing telephone interviews is one of the most efficient and effective ways to perform such surveys and receive feedback data. For one, it helps mitigate the time involved to perform the interview process. Using a third party allows the agency to focus on what it does best—EMS response and clinical care—and prevents potential bias claims.

Paramedics Plus commissioned the Baldrige Group, a performance consulting firm, to conduct its patient experience phone surveys. Third-party companies such as this specialize in conducting surveys and have experience and insight into how to achieve the desired return rates. 

The Baldrige Group is responsible for conducting enough interviews to meet the required sample size, and Paramedics Plus only pays for completed surveys. Now the exact sample size number desired is received each month—a 100% return rate—which provides confidence that the data collected is valid and representative of the patients receiving care.

Survey feedback data is provided as top-line and segmented web reports in areas such as patient demographics, zip code and shift, allowing leaders to identify variations in performance. 

Agencies can also benefit from the aggregate data third-party companies can access. For example, EMS agencies can benchmark their performance against results from systems of similar size. 

Using the Results

Feedback is useless unless an EMS agency has a strategy to use it to improve patient care and experience. 

Paramedics Plus has been using patient experience feedback in its strategic planning process for years, and it recently increased its emphasis in this area. As a result the company has high satisfaction scores in its five operations and now focuses on “top-box” performance. For example, Sunstar Paramedics in Pinellas County, Fla. (a Paramedics Plus operation), saw a rise in patient satisfaction from 91% in 2015 to almost 97% in 2016. So far in 2017, the patient satisfaction rate is 99%. Figure 1 depicts patient satisfaction rates for Paramedics Plus’ five operations in 2016. 

This didn’t happen by accident. It took strategic planning to determine the goals and how to achieve them.

Set a goal—Typically EMS agency leaders will look at achieving patient satisfaction, often defined as any patient who selects agree or strongly agree or good or very good in their responses (depending on the scale used). 

This is a good goal; however, once an agency achieves high scores in this area, it should then challenge personnel to achieve patient loyalty—often defined as the “top box” (strongly agree or very good). 

This top-box score indicates that if the patient had the choice of which agency would respond to their emergency, they would choose that surveying EMS agency without a doubt. The data could be analyzed down to the specific crew level to determine whether the patient would, given the choice, choose the same crew to respond. Crew-level feedback is a good opportunity to recognize employees who go out of their way to provide the best experience for patients.

Paramedics Plus’ goal is to provide the best patient experience, which translates into patient satisfaction results of 96.5% or better. As the team reaches this goal, another, higher goal is set.

Communicate the goal—EMS agencies need to understand what patients expect from their EMS experience, then communicate internal performance targets to all levels of the organization. The key is to share the goals and results with both supervisors and employees. Let them know how their station or deployment hub is performing compared to the others. Employees should know what patients expect of them and how they’re being rated in these areas. Supervisors, in turn, must reinforce these expectations with employees.

Analyze the data—Turning data into usable feedback can be difficult for EMS leaders. Often leaders start by looking at the survey results for each question. For example, if patients are less satisfied with the compassion displayed by the crew, leaders may decide to focus on that area in the agency’s training and coach all employees in that area. 

But what if data were segmented and looked at in other ways? Surveys can include demographic information to segment by zip code, rescue, ambulance unit number, shift, primary impression, patient age, gender, employees, etc. For example, in one of Paramedics Plus’ operations, leaders identified certain hubs that had higher patient satisfaction. 

Paramedics Plus uses a demographic worksheet that displays this segmentation of data to provide a better understanding of the areas that need improvement. This also allows further dissection of the results to focus on areas such as which employee work groups need additional coaching or which patient populations need more attention. This worksheet is evaluated each quarter. 

Paramedics Plus has also identified that patients with complaints related to general medical conditions record lower satisfaction results than patients with pain, shortness-of-breath or injury complaints. The clinical services department is working to identify methods that impact patient perception in these areas, and it may address the topic in future trainings or recommend ways to amend current patient care protocols.

Once leaders have analyzed the results and discovered their “a-ha” moments, they should share these results. 

Communicate progress toward the goal—A word of caution: Don’t make the mistake of only sharing the results with the organization’s management-level personnel. Share the performance (in comparison to the goal) to all levels in the organization—from management and supervisors to employees. 

Communicate expectations verbally and through posters, newsletters and employee scorecards. It’s important that communication of the goals and performance become a focus of your daily operations.
The segmented results help the agency focus on areas with the greatest impact on improvement. They allow them to find broad solutions to issues, rather than just one part of a problem. The more employees who get the results, the bigger the task force is to improve. 

Paramedics Plus has found that interactions between employees and their direct supervisors have the most impact. Employee groups, such as training officers, supervisors, assistant supervisors and leads, can assist in identifying how improvements can be made. For example, if displaying a caring and compassionate demeanor is an area for improvement, how will the agency as a whole improve in this area? Enlist the help of various employee groups to come up with actions they feel would be helpful. They may have ideas to create a fun video displaying the best way to show compassion or develop a full-blown patient experience training curriculum for orientation and annual training events. 

Sometimes just a friendly peer-to-peer competition between hubs, crews or shifts, with some recognition for being a top performer, can be a catalyst for improvement.

Meeting Expectations

When patients call 9-1-1, they have certain expectations for the service they receive. Knowing what these expectations are and assessing the patient’s perception of their EMS experience is important. If EMS providers want to show the value they provide to their communities, they need to evaluate patient feedback and take steps to improve patient care. 

The survey process and level to which agencies use the results are vital components to improve initiatives and provide the best patient experience to a community.

References

1. Customer Service Manager. Customer Service Facts, https://www.customerservicemanager.com/customer-service-facts/.
2. Department of Health and Human Services, Centers for Medicare & Medicaid Services. Hospital Value-Based Purchasing, https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf.
3. Beard R. Online Surveys Vs Phone Surveys. Client Heartbeat, https://blog.clientheartbeat.com/online-surveys-vs-phone-surveys/.

Photos courtesy Jim Pennington

Debbie Vass, RN, EMT-P, is director of quality initiatives for Paramedics Plus. She oversees corporate strategic planning, quality dashboard implementation and the company’s overall vision. Vass has worked as chief administrative officer, director of clinical services, registered nurse and paramedic for Sunstar Paramedics in Pinellas County, Fla. (a Paramedics Plus operation).