Three days later you are summoned into the chief’s office and asked to explain a complaint letter written by a prominent local attorney, Ms. Jones’ son. The two-page complaint describes his dissatisfaction regarding his mother’s care and the severe pain she suffered prior to arrival at the hospital. The chief requests a full explanation, yet the strict adherence to protocol falls on deaf ears. “This patient was unhappy and therefore the care she received was subpar!”
The Patient Satisfaction Dilemma
Patient satisfaction is a hot button term in healthcare. Most providers shun the idea of having to cater to patients with the hope of generating positive feedback when a random survey is sent in the mail. Administrators, on the other hand, are fully sold on the outcomes of patient satisfaction surveys and often times base bonuses and promotions on their results. The patient satisfaction metric is fully embedded in the American healthcare model and to that end; it deserves a closer look at how EMS professionals can use it to improve the overall patient experience. Some view patient satisfactions as an irrelevant barometer of the quality of care and despise the value administrators assign to it. Viewed from a different lens however, the principles of psychological science can shed light on the matter and give healthcare providers specific techniques that will positively change their practice.
What is Happiness?
Many psychologists have tried answering this age-old question, yet it turns out to be a difficult one to answer. How is it even possible that Ms. Jones could have been happy with the care she received while experiencing severe pain? The answer comes from Nobel Prize winning psychologist, Daniel Kahneman, PhD, who discusses this intriguing topic in his 2011 best seller, “Thinking – Fast and Slow.” Kahneman describes a fascinating concept regarding how people experience events versus how they remember those events. The experiencing self and the remembering self are completely separate entities. One is experiencing the actual events as they happen, while the other recalls those events some time later. An understanding of this critical concept, described so eloquently by Kahneman, is the key to unlocking the patient satisfaction mystery. Take for example two patients who are undergoing a colonoscopy without anesthesia. The first patient’s procedure was short, but consisted of 8/10 pain, mostly concentrated at the end. The second patient had a longer procedure with a reported 6/10 pain, yet the pain was early in the procedure and not at the end. Intuition may cause you to believe that the first patient (8/10 pain – short procedure) would be more satisfied than the second patient (6/10 pain – long procedure), however that turns out not to be the case. What Kahneman demonstrates, using numerous examples, is that patients remember two specific things about a painful experience. First, they remember the PEAK of their pain and second, the END of the experience. Those two critical inflection points are the staples of the remembering self, regardless of what the experiencing self lived through. Kahneman calls this the Peak-End Theory.
Experiencing Self vs. Remembering Self
To understand this phenomenon better try and recall a vacation you took in the distant past. There is a good chance that you will be unable to recall the individual moments you experienced during the trip and when you call on your remembering self to paint a picture of the vacation, it will, according to Kahenman, remember the PEAK and the END. In other words, your brain will recall the height of your happiness — or sadness — during the trip, as well as the end of the experience. This Peak-End Theory of happiness holds true for the patient experience, as well, and provides clues towards unlocking the mystery of patient satisfaction. The EMTs treating Ms. Jones surely felt that their inability to treat her pain would destroy any chance of her being a happy customer. According to Kahneman’s theory, this could not have been further from the truth. What Ms. Jones experienced and what she ultimately remembered from her pre-hospital experience were two distinct items. First was the PEAK of her despair; not knowing if her cat ran out of the front door was more painful than the multiple attempts at an IV. Finally, the END of her pre-hospital experience was also miserable; it was a bumpy ride on a hard backboard into the cold and glaring emergency department that was ultimately consummated with a painful transfer to another group of strangers. So while the peak of the experience is important, the end is perhaps even more memorable. This concept is not new, and has been used by major companies around the world for decades. One excellent example is the Ritz Carlton hotel chain.
The Ritz Carlton’s Fond Farewell
Juan Cardona was a young man in his late teens when he arrived from Colombia in search of the American Dream. After working for the airlines for a couple of years, he landed a job as a security officer at the Ritz Carlton Hotel, an experience that would change his life forever. The hotel’s motto, “ladies and gentlemen serving ladies and gentlemen,” was a clear statement of the type of customer service environment the Ritz-Carlton Hotel wanted to instill in its employees. Excellent customer service, they preached, starts with how internal customers treat one another. The first day on the job, Juan’s manager made one thing very clear, every departing hotel guest should be given a fond farewell. The concept was simple; exaggerate the farewell in order to make their departure memorable. The commitment of the hotel was so strong, it provided him with a Ritz Carlton credit card to be used strictly for the purpose of enhancing the guest’s experience. Juan recalls a family that was waiting for a taxicab for five minutes and began to become restless. He quickly raised his hand to summon a nearby limousine driver. He invited the family to take a seat in the limo for their “on the house” ride to the airport. It was an experience they’d never forget and an amazing END to a fantastic trip. In another instance, a guest was about to celebrate his birthday. His request was clear, he wanted fireworks by the pool to make the day memorable. At the last minute, the guest changed his mind and decided that instead, he wanted his room filled with balloons. In a short period of time the hotel guest service director reached out to every department. Hotel employees were sent to search for all types of inflatable balloons in the adjacent town in order to fill the 12,000 square feet hotel ballroom with balloons. After an exhausting couple of hours and with almost every hotel employee helping, the task was accomplished, and the guest celebrated his birthday, just as he wanted to. This was the Peak-End theory of customer satisfaction at work! Thirty years later, Juan Cardona is still practicing the same type of care, only now as the EMS Chief for Coral Springs Fire Department. He understands the value of peak experiences and fond farewells and his positive attitude is contagious. Chief Cardona now teaches the same principles he learned decades earlier to ensure that the citizens of his jurisdiction receive the best care possible. During the final moments of the EMS encounter — drop-off in the ED — a time when most personnel are intimidated by the hospital environment, Chief Cardona asks his crews to give each patient a fond farewell.
The Ms. Jones Redo
How could these principles have helped the crew who treated Ms. Jones, prevent her negative feelings and positively impact her outlook during a negative situation? Here is a simple list that can be used for most patients evaluated and treated by EMS.
- Exaggerate the introduction
- Ask, don’t tell
- Do something special
- Fond farewell
Exaggerate the introduction
First introduce yourself and your crew by name
Next ask each person in the room their name and their relationship to the patient
Be cautious not to assume the relationship — mother, daughter etc. — of the person to the patient, always ask them to provide the answer
Repeat your name again and state that you are here to help
Ask, don’t tell
Rather than tell someone they need an IV, ask them if it’s OK if you place one
Asking a patient for permission gives them a sense of control over an uncontrollable situation
If the tone is correct the patient will almost always say “yes, go ahead”
Telling a patient you “are sorry” that they feel this way is important
Anything painful should be sandwiched by two apologies
Do something special (PEAK)
Closing Ms. Jones’ front door and letting her know that the cat is safely inside is one example
Calling a worried family member and comforting them is another
Fond Farewell (END)
This is the biggest deficit in EMS today, but the solution is simple
Exaggerate the exit, similar to the introduction
Thank the patient, wish them a speedy recovery and then ask if they have any questions for you
Provide the patient and/or family with a department business card — not a personal one — so they can call the administration and brag about your care
Patient satisfaction can sometimes feel like a burden to the health care provider, especially when the situation, based on the circumstances, is negative from the outset. It turns out, however, that making someone “happy” during a time of pain and suffering is complex, yet not as negative as it would appear on the surface. Dr. Kahneman enlightens us with evidence-based studies of happiness that are based on decades of psychological research for which he won the Nobel Prize. These simple concepts are quickly transferable to the bedside and can be used on every patient, every day.
I have found these tools very useful myself and put them to work on every shift in the emergency department as well as the pre-hospital setting. As an EMS medical director, I offer a monetary reward, at the end of the year to the EMT who receives the most emails or phone calls from satisfied patients. One of the agencies I work for has agreed to match the reward, and in only six months we have seen a dramatic shift in patient and provider satisfaction. It’s a recipe for success with a Ritz Carlton shine!
Peter Antevy is an EMS Medical Director: Davie Fire Rescue, South West Ranches Fire Rescue, American Ambulance Services. He is an EMS Associate Medical Director: Coral Springs Fire Rescue, Plantation Fire Rescue, Seminole Tribe Fire Rescue, Margate Fire Rescue, Sunrise Fire Rescue and Miramar Fire Rescue. Antevy serves as Medical Director: Broward College EMS Program and is Pediatric Emergency Medicine Physician: Joe Dimaggio Childrens Hospital. He is founder and Chief Medical Officer: Pediatric Emergency Standards, Inc. Antevy is Associate Professor of Pediatrics: Florida Atlantic University School of Medicine.