Strategies to Improve Press Ganey Scores (serious)

[Backpack234]

Serious replies only please. Anyone with proven strategies to improve scores?

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[cyanide12345678]

Dilaudid.

 

[Birdstrike]

Always, always, always, ask yourself, "What does this patient want out of this visit?" If you can't easily figure that out, just ask them! There's usually a very specific thing that triggered the decision to venture into the misery of a packed ED waiting room. It's often completely different than what you expect, and different than what your training has taught you. Once you determine that, helping them get what they want out of the visit goes a long way, if possible and if reasonable.

A classic example is the 3 am crying kid with a fever. It's likely mom didn't bring in the kid to learn "there's no sepsis" and "your kid just has a virus, so you didn't need to be here," while 'you wasted everyone's time,' oozes out of your pores. Odds are she's there because the kid is up crying, keeping mom and the whole family up, causing distress. Getting that kid feeling better so he/she can sleep, so the whole household can sleep, can save a whole family's whole week.

Even a miserable ED experience can be saved for someone if they feel you were fighting to address what they wanted out of the visit, in addition to providing standard-of-care Medicine.

 

[southerndoc]

AIDET training is helpful.

Don't ever belittle a patient's complaints. It may trigger a complaint, but will always guarantee a bad survey. Never belittle another provider. If urgent care sends you in something stupid, don't say that. It'll make you look bad.

Use the Disney approach. Tell them something is going to take 1.5-2 times longer than it normally does. If you give an expectation that a CT will take 2 hours to be done and read, but it's done in 1, they are immensely happy. It's a psychological effect. Of course, don't tell them 2 hours if it's going to take 6 because they will be even more irritated than you telling them that you didn't know.

If they ask a question, don't ever answer with "I'm not sure" or "I don't know." Always tell them you'll look into it. Once I was asked when the cafeteria closed, and I had no idea because they change hours often during the week. My reply: "Honestly, they change hours so often that it's hard to say. Let me find out for you." The family was extremely pleased that I took time to find out the cafeteria hours and wrote a letter thanking me to the CEO. It's the little things -- it always is.

Finally, if a patient asks for something to drink or is shivering like they're cold as all get out, then bring them a cup of ice water, Gatorade, blanket, etc. yourself. This is a double win. You win extreme points with the patient and family, and if a nurse sees you you'll get extreme points with the nurses. You'd be surprised at how I've gotten great surveys from patients that were in the waiting room for 6+ hours all because I brought them a cup of water or a blanket. If I see someone who looks cold, frequently I don't even say anything, I walk out of the room after my history/physical exam, grab a blanket, and bring it to them. They're always surprised and feel well cared for that you noticed they were cold, they didn't need to ask, and you took care of them. Again, it's a psychological effect.

A lot of times surveys are returned not based on care, but instead based on how they were treated. Make a patient feel welcome and you'll get a great survey. Provide the best treatment ever and make them feel unwelcome or a bother to you, and you'll get a bad survey.

My reply is not meant to debate the merits of whether surveys are warranted or not. I hate them and think they shouldn't occur. However, I do realize how much hospital administration places on them and have learned to play the game. When it's tied to a CEO's bonus, it's a number one priority to them.

 

[Backpack234]

Thank you for the replies. So far very helpful. And apparently some things I didn't realize until now that could have saved me a lot of grief.

 

[docB]

Echo Birdstrike and southerndoc and for the record I think "customer" satisfaction in EM is bad for EM, healthcare in general and society, but as SD said, discussion for another time.

Here's something I've found helpful that hasn't been brought up. I like to make a quick, last minute appearance right before they leave. This is after I did the summation visit about findings, how they're feeling, what I'm going to prescribe etc. Now that most of us are using Eprescribe stopping in to verify their pharmacy is a good reason. I poke my head in the door as they're getting ready to leave, verify it and tell them I hope they're feeling better. The plusses are that they see me again and the 5 second pop by seems to be about as valuable as a full 5 minute chat. The specific question limits the kind of stream of consciousness philosophizing that "Do you have any questions?" seems to bring and it never results in the dreaded retelling of the HPI. It gives them one last chance to ask questions if they actually have something specific. You can cap it off with something like "Great. I'm sending them right now!" which sounds enthusiastic.

As for PG in general here's a "joke" tell my students and residents which is one reason I'm in trouble a lot.
How do you know when you went into the wrong industry? When your scripting demands you begin every encounter with an apology.
How do you really know when you went into the wrong industry? When you have scripting.

 

[bravotwozero]

Ask them 'is there something you're worried about?'. Most important IMO

 

[Cinclus]

To add onto SouthernDoc's stuff: Sit down in the room. Increases the perceived amount of time you spent with them. I always thank them for their patience, no matter what the wait times, and apologize for any delay. If there was a longer wait, they are happy for it to be acknowledged. If not, they will say things were speedy. Either way, they generally tell me, "No problem." When I enter, I say hello to the patient, introduce myself, and if anyone is with them, I then ask who it is, and I say hello to them as well. These things take hardly any time, but they really set the stage that you are a nice, caring person. I often say all this while I am grabbing the stool and sitting down with them. And then we get to the,"How can I best help you today?" And continue the usual. I also will summarize the tests and treatments we are going to do before I leave the room, what they're for, etc. Tell them any plan I may have at that time, or what we need to wait for before we can finalize a plan. Set expectations, tell them how you're helping them.

 

[turkeyjerky]

One thing I always have trouble with is being able to maintain these behaviors when I'm busy, frustrated (with patients or the system) or with unreasonable patients. In my mind there are, more or less 3 types of patients we see:
1. Patients who require emergent care, most being admitted (or discharged after appropriate care, eg a dislocation or asthma attack)
2. Normal people w/ non or 'ruled-out' emergent conditions
3. Crazy people or those w/ unreasonable expectations

The first group are easy--they're generally satisfied, but are usually admitted and don't get a PG. The second are either happy enough with appropriate care, or are amenable to the strategies discussed above (and it's not that painful to do so).

The third group is the problem. Although you can sometimes pacify them with aidet or the 'test, shot and script' approach, it just sucks the life out of you after a while. I just have a hard time cleaning that spot sometimes:

 

[Apollyon]

1. Patients who require emergent care, most being admitted (or discharged after appropriate care, eg a dislocation or asthma attack)
2. Normal people w/ non or 'ruled-out' emergent conditions
3. Crazy people or those w/ unreasonable expectations

Incidence of these pts occurring:

3>>>1>>>>>>2 (and, 2 is the largest subset of 1)

I've said - for years - that the only time we see normal people in the ED is after trauma (ranging from a finger lac to rolling over their car) or if they have crushing chest pain.

 

[GeneralVeers]

I don't worry about Press Ganey at all. The amount our site incentivizes for getting good Press-Ganey simply isn't worth the effort. Even being a "non-empathetic" doctor, I still get the bonus 50% of the time without actively trying.

Back when I first started EM and actually looked at my scores (I don't bother now) it seemed random. Some months I'd be near the top of the list, and some months at the bottom. The statistical sampling is such that one bad score destroys you.

Unless you are being threatened with your job if you don't improve, it's simply not worth worrying about.

 

[Birdstrike]

AIDET training is helpful.

Don't ever belittle a patient's complaints. It may trigger a complaint, but will always guarantee a bad survey. Never belittle another provider. If urgent care sends you in something stupid, don't say that. It'll make you look bad.

Use the Disney approach. Tell them something is going to take 1.5-2 times longer than it normally does. If you give an expectation that a CT will take 2 hours to be done and read, but it's done in 1, they are immensely happy. It's a psychological effect. Of course, don't tell them 2 hours if it's going to take 6 because they will be even more irritated than you telling them that you didn't know.

If they ask a question, don't ever answer with "I'm not sure" or "I don't know." Always tell them you'll look into it. Once I was asked when the cafeteria closed, and I had no idea because they change hours often during the week. My reply: "Honestly, they change hours so often that it's hard to say. Let me find out for you." The family was extremely pleased that I took time to find out the cafeteria hours and wrote a letter thanking me to the CEO. It's the little things -- it always is.

Finally, if a patient asks for something to drink or is shivering like they're cold as all get out, then bring them a cup of ice water, Gatorade, blanket, etc. yourself. This is a double win. You win extreme points with the patient and family, and if a nurse sees you you'll get extreme points with the nurses. You'd be surprised at how I've gotten great surveys from patients that were in the waiting room for 6+ hours all because I brought them a cup of water or a blanket. If I see someone who looks cold, frequently I don't even say anything, I walk out of the room after my history/physical exam, grab a blanket, and bring it to them. They're always surprised and feel well cared for that you noticed they were cold, they didn't need to ask, and you took care of them. Again, it's a psychological effect.

A lot of times surveys are returned not based on care, but instead based on how they were treated. Make a patient feel welcome and you'll get a great survey. Provide the best treatment ever and make them feel unwelcome or a bother to you, and you'll get a bad survey.

My reply is not meant to debate the merits of whether surveys are warranted or not. I hate them and think they shouldn't occur. However, I do realize how much hospital administration places on them and have learned to play the game. When it's tied to a CEO's bonus, it's a number one priority to them.

My version of this is to say, "Come from a place of 'yes.' Don't come from a place of "no."

What I mean by that is, when someone asks you for something you can't give or do, and you come back with a hard, "No," they never like it no matter how correct you are. You can just as easily say no, by saying, "Yes, but when you're upstairs in your room," or, "Yes, you'll get your MRI when you see ortho this week," etc. It's a subtle but persuasive difference. It creates the perception that you're not saying no, but instead are you're saying yes, with a qualifier.

"Yes, but..." always sound better than, "No."

 

[Birdstrike]

Also, read these two books.

How to Win Friends and Influence People, by Dale Carnegie, and

Influence (The Psychology of Persuasion), by Robert Cialdini.

Not only will they help you in Medicine, but they're help you in life and change how you view the world. Literally.

 

[alpinism]

Its easy just pretend you're working as a prostitute.

Say what they want to hear and make them feel good.

 

[bravotwozero]

Its easy just pretend you're working as a prostitute.

Metaphorically speaking, that's exactly the case anyway....

 

[lp430]

I work locums so I don't ever see PG, but before I leave most patients rooms I ask if they have any additional questions or concerns. I let them know my name again and that I'll be there for them if anything comes up. Seems to work well so far and doesn't take much extra effort. I also sit down, but that's more for me...

 

[Apollyon]

Seems to work well so far and doesn't take much extra effort. I also sit down, but that's more for me...

"By hook or by crook"!

 

[Old_Mil]

Always, always, always, ask yourself, "What does this patient want out of this visit?" If you can't easily figure that out, just ask them!

A classic example is the 3 am crying kid with a fever. It's likely mom didn't bring in the kid to learn "there's no sepsis" and "your kid just has a virus, so you didn't need to be here," while 'you wasted everyone's time,' oozes out of your pores. Odds are she's there because the kid is up crying, keeping mom and the whole family up, causing distress. Getting that kid feeling better so he/she can sleep, so the whole household can sleep, can save a whole family's whole week.

So question...in this patient scenario who do you give the Dilaudid to...the kid, or the mom?

 

[Groove]

I pull up a chair next to the patient and sit down for many of my encounters. Pt's perceive that are you spending much more time with them than if you are actually standing over them or at the foot of the bed. I try to force myself to ask at least one thing about them personally such as where they are from, or comment on something they mention, etc.. Always circle back after everything is completed, sit back down and explain the results, follow up, etc.. I try to touch them on the arm or pat their leg before I leave. Pt's for some reason remember little things like that and the circling back to close the loop is the last thing they remember and many times the clearest thing they remember from the entire encounter. Otherwise, the AIDET approach mentioned earlier is right on the money.

Also, don't forget to talk, engage, compliment the family member or close friend that is sitting with the pt. Many times they are the one actually filling out the PG form for the patient at home!

 

[dadaddadaBATMAN]

One thing I always have trouble with is being able to maintain these behaviors when I'm busy, frustrated (with patients or the system) or with unreasonable patients. In my mind there are, more or less 3 types of patients we see:
1. Patients who require emergent care, most being admitted (or discharged after appropriate care, eg a dislocation or asthma attack)
2. Normal people w/ non or 'ruled-out' emergent conditions
3. Crazy people or those w/ unreasonable expectations

The first group are easy--they're generally satisfied, but are usually admitted and don't get a PG. The second are either happy enough with appropriate care, or are amenable to the strategies discussed above (and it's not that painful to do so).

The third group is the problem. Although you can sometimes pacify them with aidet or the 'test, shot and script' approach, it just sucks the life out of you after a while. I just have a hard time cleaning that spot sometimes:

I think most of the things that I do have been said. It makes me feel a little slimy, but getting good press ganeys is one of my natural talents, and group 3 is my specialty


The key thing with the crazy people is a combination of good showmanship and understanding why they are there.

If someone comes in with 5 years of abdominal pain and I satisfy myself that there is no actual emergency (5% of the time they tell you about the sudden worsening that happened two hours before they got there which migrated to the rlq from the periumbillical region), I do a couple things.

1. “Wow! You’ve been suffering like this for five whole years? How terrible. I can only imagine how you’re making it through the day”. Or equivalent statement. 4/5 of these people are here Because they want their insane, crazy symptoms validated. Usually it’s most important to validate it to their cheerleader (mother, husband, wife, whatever) in the corner.

2.) establish expectations and the near 0% chance that you will ever figure this out. Create a therapeutic alliance if possible.

“I’ll be honest, if you’ve been to 17 different gi doctors and surgeons I don’t know if I will figure this one out. ill Make sure that you’re safe for now, but we’re probably still going to have work to do after this.”

3.) turf. Turf like your life depends on it. “What I probably can do if we can’t figure it out is at least get you into a specialist who can give you an 18th opinion. I know a *really* good gi doc (insert doc on calls name). If we can’t figure it out tonight I want to try to get you into see dr. Gi On call.

4. Return to room with negative results. Here your job is validate their complaint again and tell them you are “glad you came in, because I wouldn’t want you to be scared at home, but we’re not seeing anything that would make you unsafe right now. It doesn’t mean that what you’re feeling is real, that it isn’t important, or that we’re done. It just means that there isn’t anything we can operate on or fix with an admission. If things get worse please do come back (after my shift please please for the love of god), because it changes the way we look at things ”

General thoughts on my approach:
1. I do this for practical reasons. These people almost never fight me at the end of the work up and they’re usually ok to go. Takes way less energy than fighting, and less time (unless you go full scorched earth, which is ill advised because then you get an ombudsman complaint/ lots of emails next day)

2. Listen as much as you can stand to. I’m not saying sit there 20 minutes, I’m saying about 5 actual minutes. It’s why they came in. It will also save you time fighting later, it makes you seem more caring, and it’s faster than cross sectional imaging or us they’ve had 8 times. My script for imaging is “ i see you had 7 ruq us, 4 cts, and 8 tvus in the last month. I see they didn’t figure it out with those: I can order those, but I think it doesn’t really make sense and it’s just going to make your bill bigger. It’ll make my bosses in the hospital happy but I don’t think it’ll help you, so let’s not knee jerk to the same thing we do every time. We really need to get you to see dr. Gi on call soon to help figure out if a scope or pill cam or other test I can’t do can help”

3. If it’s not attention and validation they’re seeking, identify it early: sometimes it’s symptom relief. If that’s the case I mostly just give helpful (and more importantly harmless) placebos, and make it absolutely clear from the first moment I’m in there that opiates are not gonna happen (I have the lowest script rate in my group).

4.) never drop the facade, and if they get angry start telling them you care about them every other sentence (especially if you don’t). It’s hard to argue with, and it’s hard to email an ombudsman “he said he cared about me and so he wasn’t ordering a test or unnecessary meds that would charge me!”

 

[gutonc]

Echo Birdstrike and southerndoc and for the record I think "customer" satisfaction in EM is bad for EM, healthcare in general and society, but as SD said, discussion for another time.

Here's something I've found helpful that hasn't been brought up. I like to make a quick, last minute appearance right before they leave. This is after I did the summation visit about findings, how they're feeling, what I'm going to prescribe etc. Now that most of us are using Eprescribe stopping in to verify their pharmacy is a good reason. I poke my head in the door as they're getting ready to leave, verify it and tell them I hope they're feeling better. The plusses are that they see me again and the 5 second pop by seems to be about as valuable as a full 5 minute chat. The specific question limits the kind of stream of consciousness philosophizing that "Do you have any questions?" seems to bring and it never results in the dreaded retelling of the HPI. It gives them one last chance to ask questions if they actually have something specific. You can cap it off with something like "Great. I'm sending them right now!" which sounds enthusiastic.

As for PG in general here's a "joke" tell my students and residents which is one reason I'm in trouble a lot.
How do you know when you went into the wrong industry? When your scripting demands you begin every encounter with an apology.
How do you really know when you went into the wrong industry? When you have scripting.

How did nobody point this out yet?

HOLY S*** @docB IS BACK!!!!

@docB and the "Things I Learned From My Patients" thread is the whole reason I even found SDN back in the day

 

[RustedFox]

This whole thread is 90% of the reason why EM is a farce in this nation.

When you have to game-ify a scoring system to maintain job security, it's very telling that "were doin it rong" (sic).

 

[Backpack234]

Thanks to everyone for the help. I am a doc facing unemployment if my scores don’t improve. But I think your help will be valuable and hopefully keep me from having to explain an extended gap (thanks covid)

 

[Birdstrike]

How did nobody point this out yet?

HOLY S*** @docB IS BACK!!!!

@docB and the "Things I Learned From My Patients" thread is the whole reason I even found SDN back in the day

Yes! I commented on him being back this time last year, when he emerged nonchalantly out of nowhere after a 6 year hiatus. Honestly, he left so suddenly and without explanation that I was a little worried. It’s great to have you back, @docB.

 

[Birdstrike]

This whole thread is 90% of the reason why EM is a farce in this nation.

When you have to game-ify a scoring system to maintain job security, it's very telling that "were doin it rong" (sic).

Our training: 99% Medicine, 1% other gobbledygook.

In practice, all anyone cares about: The 1% gobbledygook.

 

[docB]

How did nobody point this out yet?

HOLY S*** @docB IS BACK!!!!

@docB and the "Things I Learned From My Patients" thread is the whole reason I even found SDN back in the day

Thank you and thanks for noticing. I try to lurk as often as I can because I believe in the site and the quality of most of the discussions. I also think there's a therapeutic quality to it which is why I was bouncing around yesterday. Maybe I'll go ahead and post that thread I was thinking of. I didn't leave for any reason. I think I was in a pretty dark place career wise and just quit being able to talk about it. Someone said to me a few years back "You're not burnt out if you're still trying to make things better." I thought that was really true, then I kind of quit trying for a while. I'm in a better place now and I'm starting to try to improve things again.

That said, and so as to not totally derail the OP, I do agree with Veers. If you don't have some huge mandate to care about PG don't. I just want to stay in the bell curve and not get called in for the "coffee talk."

 

[RustedFox]

Thank you and thanks for noticing. I try to lurk as often as I can because I believe in the site and the quality of most of the discussions. I also think there's a therapeutic quality to it which is why I was bouncing around yesterday. Maybe I'll go ahead and post that thread I was thinking of. I didn't leave for any reason. I think I was in a pretty dark place career wise and just quit being able to talk about it. Someone said to me a few years back "You're not burnt out if you're still trying to make things better." I thought that was really true, then I kind of quit trying for a while. I'm in a better place now and I'm starting to try to improve things again.

That said, and so as to not totally derail the OP, I do agree with Veers. If you don't have some huge mandate to care about PG don't. I just want to stay in the bell curve and not get called in for the "coffee talk."

Please post your thoughts.
2020 was a dark time for me, career wise as well.

 

[Backpack234]

OP here. This thread has been very helpful. But 2020 was bad for me too. Feel free to use this thread if you’d like or create a new one cuz I’m sure we all have our 2020 career stories

 

[bravotwozero]

OP here. This thread has been very helpful. But 2020 was bad for me too. Feel free to use this thread if you’d like or create a new one cuz I’m sure we all have our 2020 career stories

Please post your thoughts.
2020 was a dark time for me, career wise as well.

Well, that makes at least three of us. Misery loves company.

 

[em1234]

I posted this almost 6 years ago, where has the time gone, in a similar thread about PG. Though everything mentioned above, sitting down, getting blankets, etc has been shown to improve scores, a system one of my old medical directors cooked up years ago worked really well. Stuffing the ballot box. I didn't feel like rehashing the whole post, so I just copied and pasted it. Hope this helps.

Apr 2, 2015

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• #16

Know your enemy!
At my current CMG outpost we were tired for being the hospital system's P-G whipping boy. The other 6 hospitals in the system are in much more affluent areas, with a good payer mix and generally pleasant people. My hospital is the urban poor, knife and gun club, uninsured is our primary insurance kind of facility. Some refer to it as county-plus.
Our medical director, sick of monthly graph and charts that said we were all terrible Press-Ganey-tologists, set out to demystify the system. Too much hearsay and old wives tales about who gets a survey and who doesn't. Diagnose them with X and they won't get a survey, put drug seeking behavior on the chart, no survey, etc.
It has turned out that knowing our enemy has been the key to winning the war.
Who actually gets excluded:
1. AMA, LBSW, medical screen out
2. admitted and transferred pts
3. DOA pts
4. peds pts dc'ed to custody of DCFS
5. pts who are dc to jail/police
6. Pts who threaten staff with physical harm
7. Repeat visit in the last 3 months, provided they had received a survey already.

There you go. That's the list. Primary or secondary psych disorder diagnosis? Survey. Rape or physical assault victim? survey. Drug seeking behavior/high utilizers? survey. Homeless? Survey. Miscarriage? Survey.

In light of the new information and finding out most of our assumed P-G exempt pts were getting survey's all along, we have made some changes. Oh, and in case anyone was worried, Santa also is not real, but it wouldn't stop P-G from sending him a survey.
Screening out patients has increased. An example: Generally well pt, nl vs, no SI or HI who comes in thinking there is a parasite or animal crawling around inside of him. Wants labs and a scan to "find what's wrong with him!!" Screen out. not enough labs and scans in the world to make this guy happy. Don't risk the bad P-G when the work up inevitably comes up negative.
I recognize screening out pts, isn't for everyone. One of the joys of working in Texas. My old job, this never would have flown, MSE'ing as a disposition didn't even exist.

The second battlefield in this two front war we are waging on P-G is nothing short of good old fashion Chicago-style ballot box stuffing. I see 300-350 pts per month and my monthly PG eval is based on 1-8 surveys per month, thus we have taken to using their pitiful sample sizes against them. Invariably, everyday there are plenty of patient encounters that are great. Appreciative, happy patients, good results that we bemoan "if only THESE people got a survey". Well who knows? Maybe they do and like any normal person when they get a call from a telemarkety number and some disinterested clown on the phone asking to get them to fill out a survey tells said clown "no" or pretends their house just caught fire and hangs up. We have taken to asking these happy appreciative people to keep an eye out for the patient satisfaction phone call or paper survey that may come in the next 6 weeks and should they get called, I ask them to do me a favor and take the call, do the survey and hopefully they thought we did a "Very good" (but not an excellent) job, only very good counts. I tell them that it helps me out greatly and without fail they seem genuinely happy and excited to do it. It even appears as though people are actually following through, the first 3 months of our new PG "initiative" (Read:ballot box stuffing/screen out bonanza) has led to a marked improvement in our scores across the board and a lot less chalk talks about how to better kiss backsides.

As has been previously stated, we let the genie out of the bottle when we as a profession sat idly by and were complicit in letting the patient satisfaction cancer become part of our practice. Unless someone has a delorean that can go 88mph with a Mr. Fusion and a flux capacitor there is no way to put the genie back in the bottle. That cancer has metastasized, we are now going to be reimbursed based on lay people's perception of our care. In the same way that I should be able to judge my airline pilot for getting me to my destination safe and alive, but somehow should be able to deduct money from the cost of my ticket because they ran out of coke zero, didn't play the movie I wanted and I felt the flight attendant's overhead announcements were too loud. To quote the great Jimmy V, all we can hope to do is "survive and advance". Hope this was helpful to some. Attached is the actual PG list of inclusion/exclusions.

Know the rules, play the game, and play to win,
-1234

 

[docB]

I hear you guys. I'll post a separate thread about the difficult stuff.

I'm really sorry to hear Backpack say that their job is on the line for their PG. That should just never be the case. Because of that I'm going to take the gloves off and mention some methods of improving scores that are more controversial. The fact that these work shows the weakness of PG (or Gallup, HCAHPS, etc.) as a metric.

First off I suggest you find out who the PG manager is for your practice or hospital. You need to find out some specific things about how the surveys are done and who they choose to send them to. If it's your group that contracts with the survey company it'll be easier to get answers. If it's the hospital you may need to figure out who in your group knows the system and pick their brain.

- You should concentrate your PG efforts (all the stuff mentioned in all the previous posts) on those patients likely to receive a survey. In most programs EP satisfaction surveys are only sent to discharged patients with an address. I'm not going to get into how all these things illustrate the weakness of PG, it'd get too long. Just know that it's a better use of time in the PG sense to kiss up to the suburban stubbed toe than the legit admit or the homeless guy.

- Some programs have certain diagnoses that cause a survey not to be sent. These can include psych, malingering, drug seeking, chronic pain or others. Knowing which of these are used as a screen in your system can allow you to exclude these patients from your extra efforts.

- Many systems that survey for practices that use both EPs and APPs only solicit impressions about the physician. One system I'm aware of had success with that by using a "good doc, bad app" scheme where once the target patient was identified (gonna go home, has an address) the APP would initially deny the narcs, antibiotics, cough syrup and so on. The doc would then ride in on a white horse and provide the candy with a flourish and a "I'm here for you good citizen." superhero voice. Cynical? Absolutely. Effective? Yes. Of note our leadership elected not to proceed with this as it was wildly unpopular with the APPs for obvious reasons. If you want to do this you may need to enlist your APP's support before you proceed.

- Groom the pool. If you have a difficult interaction with a patient, admit them. If you have a great interaction and you're on the fence about admit vs. d/c, let them go home.

- I haven't heard of any programs that exclude demented patients from the survey pool although some toss AMS or ALOC. If you have a demented or otherwise altered patient who is going home to a house (a SNF won't return the survey) work the family. During COVID this is easy as you can call them or go out to the waiting room and chat with them. Someone mentioned earlier that family often fills out the surveys so use that to your advantage.

I hope this helps. It's a sad state of affairs that we're reduced to this type of chicanery. Desperate times.

 

[RoyBasch]

In light of the new information and finding out most of our assumed P-G exempt pts were getting survey's all along, we have made some changes. Oh, and in case anyone was worried, Santa also is not real, but it wouldn't stop P-G from sending him a survey.
Screening out patients has increased. An example: Generally well pt, nl vs, no SI or HI who comes in thinking there is a parasite or animal crawling around inside of him. Wants labs and a scan to "find what's wrong with him!!" Screen out. not enough labs and scans in the world to make this guy happy. Don't risk the bad P-G when the work up inevitably comes up negative.
I recognize screening out pts, isn't for everyone. One of the joys of working in Texas. My old job, this never would have flown, MSE'ing as a disposition didn't even exist.

What do you mean by "screen out"? How does this prevent the patient from getting a survey?

 

[Apollyon]

"You don't have an emergent condition". The easiest to screen out are the drug seeking dental pain, recurrent nontraumatic back pain drug seeking, and things like that, that don't need anything ordered to rule out badness.

 

[RoyBasch]

"You don't have an emergent condition". The easiest to screen out are the drug seeking dental pain, recurrent nontraumatic back pain drug seeking, and things like that, that don't need anything ordered to rule out badness.

Maybe I'm really ignorant here, but I don't understand mechanistically how this precludes the patient from getting a P-G survey. Technically a large number of patient discharged have been deemed "not to have an emergent condition."

Are you telling me if you do no tests of any kind then they don't get a P-G survey?

Does it matter what you put as their final discharge diagnosis/ICD-10 code?

 

[dadaddadaBATMAN]

Maybe I'm really ignorant here, but I don't understand mechanistically how this precludes the patient from getting a P-G survey. Technically a large number of patient discharged have been deemed "not to have an emergent condition."

Are you telling me if you do no tests of any kind then they don't get a P-G survey?

Does it matter what you put as their final discharge diagnosis/ICD-10 code?

I might be wrong but I think these patients are receiving a medical screening exam in the truest sense: meaning they were seen and turned out after a doc briefly chatted with them, without being truly “admitted” to the ed.

This is obviously high risk, our department has used it to discharge Covid test seekers who have no symptoms. We call it a mse, they get a very informal note and pointed to the door. I don’t think they even get billed

 

[turkeyjerky]

I might be wrong but I think these patients are receiving a medical screening exam in the truest sense: meaning they were seen and turned out after a doc briefly chatted with them, without being truly “admitted” to the ed.

This is obviously high risk, our department has used it to discharge Covid test seekers who have no symptoms. We call it a mse, they get a very informal note and pointed to the door. I don’t think they even get billed

Some clarification would be nice. I took it to mean that s/he was just putting ‘medical screening exam’ as the final diagnosis in the chart for patients deemed likely to be unhappy, after doing whatever work up. (This would probably F your RVUs but in an hourly CMG or employed shop who cares)

 

[Apollyon]

In my first job, only at the university hospital, we had a "4-4-4" policy - 4 visits for ESI 4 or lower complaints in the past 4 months could be screened - you saw the pt, did a cursory exam, and notified them that a financial counselor would be, then, coming to see them. I didn't have a large N of pts for whom I did this, but, as I recall, not a one stayed. And they didn't get a PG.

 

[docB]

Great questions. I think the confusion here is that the way these "deferral of care" patients were handled varied dramatically by institution. In my shops it was actually a different disposition in the EMR. It changed the way they were billed and if they got a survey. A lot of the push for this went away after the ACA put everyone on Medicaid but I can see how it could be used for the cases mentioned above.

I like em1234's post above. He posted it while I was writing mine. It sounds like at his shop they don't exclude the problematic diagnoses. This points out the differences in the way that these programs are managed by different institutions and contractors (e.g. PG, Gallup). The important thing for anyone beset by the venom of satisfaction is to know what the rules are in your ED.

 

[Tenk]

Get in the room immediately, it’s the number one way to get positive reviews. I can’t tell you how many positive reviews I get where it says something like “doctor was in the room fast!” I usually am in there right as they arrive and immediately get orders going usually before they even have a gown on.

 

[bravotwozero]

...but what about the dilaudid coupons?

 

[dadaddadaBATMAN]

...but what about the dilaudid coupons?

You’re charging? That’s gonna tank you

 

[em1234]

sorry for the confusion. "screening out" is a bit of a local colloquialism for their ultimate disposition.

Everyone who comes to the ED gets a medical screening exam (the actual examination) but MSE (aka getting screened out) as docb mentioned above is also its own disposition option in our system.

Dental pain or "I want a pregnancy test, without any sxs or bleeding, just to confirm my home test" are two of my favorite complaints that usually end up with an MSE and then screened out. You go talk to them and examine them and once you have performed the legally required MSE and are comfortable that they need no emergent care or diagnostics, there are appropriate for an MSE (the disposition). in our EMR, pt's who get dispositioned as "MSE" do not get a survey.

As turkey jerky mentioned above, it isn't a great RVU generator, but at the same time these are largely level 2 visits anyway . Given it's only a patient or 2 per shift and these are the patients that are most likely to go home unhappy and have a bone to pick on their survey, I would much rather lose out on there nominal RVUs then have them on my PG call list.


Hope this clears up the confusion.
EM1234

 

[HemorrhagicShock]

sorry for the confusion. "screening out" is a bit of a local colloquialism for their ultimate disposition.

Everyone who comes to the ED gets a medical screening exam (the actual examination) but MSE (aka getting screened out) as docb mentioned above is also its own disposition option in our system.

Dental pain or "I want a pregnancy test, without any sxs or bleeding, just to confirm my home test" are two of my favorite complaints that usually end up with an MSE and then screened out. You go talk to them and examine them and once you have performed the legally required MSE and are comfortable that they need no emergent care or diagnostics, there are appropriate for an MSE (the disposition). in our EMR, pt's who get dispositioned as "MSE" do not get a survey.

As turkey jerky mentioned above, it isn't a great RVU generator, but at the same time these are largely level 2 visits anyway . Given it's only a patient or 2 per shift and these are the patients that are most likely to go home unhappy and have a bone to pick on their survey, I would much rather lose out on there nominal RVUs then have them on my PG call list.


Hope this clears up the confusion.
EM1234

To play devil's advocate here (because I otherwise agree with you fully) - aren't these the patient's with the biggest potential for a great survey in today's world of EM = "Everything Medicine"

These low acuity visits, if billed, are the ones that keep the lights on, they take literally 5 seconds of thought to rule out emergencies, and a simple script/test/whatever is more than enough to make them satisfied.

Most surveys are sent out within 24-48 hours too, so by the time they get their overcharge/notice of insurance denial of service (ha) the survey has either expired or they've forgotten about it as an option for retribution.

Perhaps this only applies to certain ER docs, because these patients don't burn me out at all. In fact, I like having a few of them per shift because they pad the numbers, are easy on the brain, and easily satisfied.

 

[RoyBasch]

sorry for the confusion. "screening out" is a bit of a local colloquialism for their ultimate disposition.

Everyone who comes to the ED gets a medical screening exam (the actual examination) but MSE (aka getting screened out) as docb mentioned above is also its own disposition option in our system.

Ok, I guess this is an idiosyncracy to your system. No hospital I have ever worked at has had this option. The patient either "leaves without being seen" or once an MSE is done (even if they later leave AMA or without therapeutic reason prior to completion of workup and formal disposition), they are technically "seen" and would still be sent a bill and possibly a P-G (unless the system has AMA/LWTR as exclusion criteria for surveys). But again there was nothing the physician could initiate out of their own volition to "remove/screen" a patient from the ER, it had to be patient initiated.

What you are describing in every system I have ever worked would simply be a low ESI level patient with a quick provider H&P/MSE, no testing, and then discharge. But this would still be a considered by the hospital, billers, coders, insurers, etc. as a full encounter for the purposes of metrics, billing, and patient satisfaction eligibility.

 

[RoyBasch]

To play devil's advocate here (because I otherwise agree with you fully) - aren't these the patient's with the biggest potential for a great survey in today's world of EM = "Everything Medicine"

These low acuity visits, if billed, are the ones that keep the lights on, they take literally 5 seconds of thought to rule out emergencies, and a simple script/test/whatever is more than enough to make them satisfied.

Most surveys are sent out within 24-48 hours too, so by the time they get their overcharge/notice of insurance denial of service (ha) the survey has either expired or they've forgotten about it as an option for retribution.

Perhaps this only applies to certain ER docs, because these patients don't burn me out at all. In fact, I like having a few of them per shift because they pad the numbers, are easy on the brain, and easily satisfied.

Perhaps this is a sign that I have become fairly cynical in my practice and strayed far from the "True Path" we are supposed to be on as ER physicians, but I completely agree with all of this.

Easy money man.

This is way better than a "dizzy" 64 year old diabetic that is most likely nothing but could be anything (cerebellar CVA, 'silent' MI, etc.)

 

[turkeyjerky]

Perhaps this is a sign that I have become fairly cynical in my practice and strayed far from the "True Path" we are supposed to be on as ER physicians, but I completely agree with all of this.

Easy money man.

This is way better than a "dizzy" 64 year old diabetic that is most likely nothing but could be anything (cerebellar CVA, 'silent' MI, etc.)

Seriously. these don’t bug me one bit. What does bug me is the people who make stuff up that demands a workup and utilizes unnecessary resources, eg the ones who aren’t happy with just a pregnancy test and make up some vaginal bleeding to get an ultrasound.

 

[thegenius]

AIDET training is helpful.

Don't ever belittle a patient's complaints. It may trigger a complaint, but will always guarantee a bad survey. Never belittle another provider. If urgent care sends you in something stupid, don't say that. It'll make you look bad.

Use the Disney approach. Tell them something is going to take 1.5-2 times longer than it normally does. If you give an expectation that a CT will take 2 hours to be done and read, but it's done in 1, they are immensely happy. It's a psychological effect. Of course, don't tell them 2 hours if it's going to take 6 because they will be even more irritated than you telling them that you didn't know.

If they ask a question, don't ever answer with "I'm not sure" or "I don't know." Always tell them you'll look into it. Once I was asked when the cafeteria closed, and I had no idea because they change hours often during the week. My reply: "Honestly, they change hours so often that it's hard to say. Let me find out for you." The family was extremely pleased that I took time to find out the cafeteria hours and wrote a letter thanking me to the CEO. It's the little things -- it always is.

Finally, if a patient asks for something to drink or is shivering like they're cold as all get out, then bring them a cup of ice water, Gatorade, blanket, etc. yourself. This is a double win. You win extreme points with the patient and family, and if a nurse sees you you'll get extreme points with the nurses. You'd be surprised at how I've gotten great surveys from patients that were in the waiting room for 6+ hours all because I brought them a cup of water or a blanket. If I see someone who looks cold, frequently I don't even say anything, I walk out of the room after my history/physical exam, grab a blanket, and bring it to them. They're always surprised and feel well cared for that you noticed they were cold, they didn't need to ask, and you took care of them. Again, it's a psychological effect.

A lot of times surveys are returned not based on care, but instead based on how they were treated. Make a patient feel welcome and you'll get a great survey. Provide the best treatment ever and make them feel unwelcome or a bother to you, and you'll get a bad survey.

My reply is not meant to debate the merits of whether surveys are warranted or not. I hate them and think they shouldn't occur. However, I do realize how much hospital administration places on them and have learned to play the game. When it's tied to a CEO's bonus, it's a number one priority to them.

Most of this is very good, but I tell patients all the time "I don't know." Because they ask me questions all the time I don't know the answer to. "Should I get a CABG?" "Should I get my knee replaced?" "Can my seasonal rhinitis be caused by black mold?" Honestly if I looked into everything they always asked me, I would be seeing 5 patients / shift.

But maybe I get bonus points because I tell them I'm just a board-certified, Ivy league trained ER doctor that knows how to safe your life! Ask me a question about that and I'll know the answer!

I don't think patients hate me as much as the regular ER doc, usually because I sit down and talk to them. If there is a chair in the room I sit down. Then I get up 3 minutes later, examine them, and leave. But for those three minutes, I'm sitting down!

 

[thegenius]

Its easy just pretend you're working as a prostitute.

Say what they want to hear and make them feel good.

"Dr. Alpinism, you are really spending a lot of time checking out my penis even though I have chest pain."

"Just want to make you feel good sir. I'm a medical *****. You are spending good money to have me at your bedside!"

 

[thegenius]

2.) establish expectations and the near 0% chance that you will ever figure this out. Create a therapeutic alliance if possible.

That is key. I say that 10 times / shift.

 

[GeneralVeers]

We have a list of exclusionary diagnoses we can use to prevent a patient from getting a PG. My favourite one is "acute stress reaction". I use this on any patient who I feel is unhappy with their visit. It's something you can put a on a chart without pissing them off further.