PLEASE NOTE: THIS RESOLUTION WILL BE DEBATED AT THE 2015 COUNCIL MEETING. RESOLUTIONS ARE NOT
OFFICIAL UNTIL ADOPTED BY THE COUNCIL AND THE BOARD OF DIRECTORS (AS APPLICABLE).
RESOLUTION:
39(15)
SUBMITTED BY:
Jeff Backer, MD, FACEP
Steven Rothrock, MD, FACEP
SUBJECT:
Patient Satisfaction Surveys in Emergency Medicine
PURPOSE: Acknowledge that higher patient satisfaction scores are associated with many indicators of poor
quality of medical care, many factors unrelated to medical care, many components of medical care not under
physician control, and to oppose the use of patient satisfaction surveys for physician credentialing or for
emergency medicine financial incentives or disincentives.
FISCAL IMPACT: Budgeted committee and staff resources.
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WHEREAS, Higher satisfaction is associated with several aspects of medicine that indicate a poorer
quality of medical care, many factors unrelated to medical care, and many components of care not under
physician control, and specifically:
 Higher satisfaction is not associated with the technical quality of medical care (in internal medicine
and emergency medicine).1
 Higher patient satisfaction is associated with a higher inpatient mortality.2
 Higher patient satisfaction is associated with a higher hospital admission rate.2
 Higher patient satisfaction is associated with increased health care expenditures.2,3
 Higher patient satisfaction is associated with increased prescription medicine expenses.2
 Higher patient satisfaction is associated with excess unnecessary back radiography in patients with
low back pain.4,5
 Higher patient satisfaction is associated with unnecessary blood work.6,7
 Higher patient satisfaction is associated excess specialty referrals.8,9
 Higher patient satisfaction is associated with unnecessary hospital admissions to expedite specialty
referrals.9
 Higher patient satisfaction is associated with inappropriate antibiotic prescriptions for upper
respiratory infections.10
 Higher patient satisfaction is associated with inappropriate narcotic prescriptions for chronic pain and
narcotic drug reactions and overdoses.11,12
 Higher patient satisfaction is associated with better baseline health, higher patient income level,
patient age, less ED overcrowding, lower ED annual census, ED fast track implementation, health
insurance status, marital status, absence of underlying baseline depression, patient acuity level,
absence of an emergency non-trauma surgical procedure, presence of a traumatic surgical procedure,
facility cleanliness, television availability, baseline ability to complete activities of daily living, postdischarge phone calls, scripting discharge instructions and post-discharge phone calls to satisfaction
survey language, and non-trauma diagnoses.13-26
 Higher satisfaction is associated with shorter wait times and throughput times in the emergency
department. Many aspects of wait and throughput times in the emergency department are not
controlled by emergency physicians but instead are related to operational factors, hospital location
(urban, suburban, rural), transfer delays, volume (overcrowding), physical size of ED, patient acuity
levels, higher nurse staffing ratios, ED size, time of day, ancillary service availability and efficiency
(e.g. lab, radiology), specialty consultant availability and responsiveness, and inpatient hospital
census.27-33; therefore be it
Resolution 39(15) Patient Satisfaction Surveys in Emergency Medicine
Page 2
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RESOLVED, That ACEP acknowledges that higher patient satisfaction scores are associated with many
indicators of poor quality of medical care, many factors unrelated to medical care, and many components of
medical care not under physician control; and be it further
RESOLVED, That ACEP opposes the use of patient satisfaction surveys for physician credentialing or for
emergency medicine practice financial incentives or dis-incentives.
References
1. Chang JT, Hays RD, Shekelle PG, et al. Patients' global ratings of their health care are not associated with the technical
quality of their care. Ann Intern Med 2006; 144:665-672.
2. Fenton JJ, Jerant AF, Bertakis, Franks P. The cost of satisfaction: a national study of patient satisfaction, health care
utilization, expenditures, and mortality. Arch Intern Med 2012; 172: 405-411.
3. Tak HJ, Ruhnke GW, Meltzer DO. Association of patient preferences for participation in decision making with length of
stay and costs among hospitalized patients. JAMA Intern Med 2013; 173: 1195-1205.
4. Kendrick D, Fielding K, Bentley E, et al. The role of radiography in primary care patients with low back pain of at least
6 weeks duration: a randomized controlled trial. BMJ 2001; 322: 400-405.
5. Miller P, Kendrick D, Bentley E, Fielding KI. Cost effectiveness of lumbar spine radiography in primary care patients
with low back pain. Spine (Phila Pa 1976) 2002; 27: 2291-2297.
6. Kravitz RL, Cope DW, Bhrany V, Leake B. Internal medicine patient’s expectations for care during office visits. J Gen
Intern Med 1994; 9: 75-81.
7. van Bokhoven MA, Pleunis-van Empel MC, Koch H, et al. Why do patients want to have their blood tested? A
qualitative study of patient expectations in general practice. BMC Fam Pract 2006; 7: 75.
8. Verbeek J, Sengers MJ, Riemens L, Haafkens J. Patient expectations of treatment for back pain: a systematic review of
qualitative and quantitative studies. Spine (Phila Pa 1976). 2004;29:2309-2318.
9. Wijers D, Wieske L, Vergouwen MDI, et al. Patient satisfaction in neurological second opinions and tertiary referrals. J
Neurol 2012; 257: 1869-1874.
10. Stearns CR, Gonzales R, Camargo CA, et al. Antibiotic prescriptions are associated with increased patient satisfaction
with emergency department visits for acute respiratory tract infections. Acad Emerg Med 2009; 16: 934-941.
11. Wallace AS, Freburger JK, Darter JD, et al. Comfortably numb? Exploring satisfaction with chronic back pain visits.
Spine J 2009; 9: 721-728.
12. Vila H, Smith RA, Augustyniak MJ, et al. The efficacy and safety or pain management before and after implementation
of hospital-wide pain management standards: is patient safety compromised by treatment based solely on numerical pain
ratings?.Anesth Analg 2005; 101: 474-480.
13. Boudreaux ED, Friedman J, Chansky ME, Baumann BM. Emergency department patient satisfaction: examining the role
of acuity. Acad Emerg Med 2004; 11: 162-168.
14. Rogers FB, Krasne M, Bradburn E, et al. Acute care and trauma surgeons: we can’t get no satisfaction – what do
satisfaction surveys measure? Am Surg 2012; 78: 731-734.
15. Nguyen TP, Briancon S, Empereur F, Guillemin F. Factors determining inpatient satisfaction with care. Soc Sci Med
2002; 54: 493-504..
16. Wolf A, Olsson LE, Taft C, et al. Impact of patient characteristics on hospital care experience in 34,000 Swedish
patients. BMC Nurs 2012; 11: 8.
17. Wallace AS, Freburger JK, Darter JD, et al. Comfortably numb? Exploring satisfaction with chronic back pain visits.
Spine J 2009; 9: 721-728.
18. Bogner HR, de Vries McClintock HF, Hennessy S, et al. Patient satisfaction and perceived quality of care among older
adults according to activity limitation states. Arch Phys Med Rehabil 2015; June 25 epub.
19. Thrasher C, Purc-Stephenson R. Patient satisfaction with nurse practitioner care in emergency departments in Canada. J
Am Acad Nurse Pract 2008; 20: 231-237.
20. Watson WT, Marshall ES, Fosbinder D. Elderly patients’ perceptions of care in the emergency department. J Emerg
Nurs 1999; 25: 88-92.
21. Olshaker JS. Managing emergency department overcrowding. Emerg Med Clin North Am 2009; 27: 593-603.
22. Jha AK, Orav EJ, Zheng J, Epstein AM. Patients’ perception of hospital care in the United States. N Engl J Med 2008;
359; 1921-1931.
23. Hwang CE, Lipman GS, Kane M. Effect of an emergency department fast track on Press-Ganey patient satisfaction
scores. West J Emerg Med 2015; 16: 34-38.
24. Rogers F, Horts M, Rogers A, et al. Factors associated with patient satisfaction scores for physician care in trauma
patients. J Trauma Acute Care Surg 2013; 5: 110-114.
25. Patel PB, Vinson DR. Physician email and telephone contact after emergency department visit improves patient
satisfaction: a crossover trial. Ann Emerg Med 2013; 61: 631-637.
Resolution 39(15) Patient Satisfaction Surveys in Emergency Medicine
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26. Lee DS, Tu JV, Chong A, Alter DA. Patient satisfaction and its relationship with quality and outcomes of care after acute
myocardial infarction. Circulation 2008; 118: 1938-1945.
27. Eitel DR, Rudkin SE, Malvehy MA, et al. Improving service quality by understanding emergency department flow: a
white paper and position statement prepared for the American Academy of Emergency Medicine. J Emerg Med 2010;
38: 70-79.
28. Cassidy-Smith TN, Baumann BM, Boudreaux ED. The disconfirmation paradigm: throughput times and emergency
department patient satisfaction. J Emerg Med 2007; 32: 7-13.
29. Hedges JR, Trout A, Magnusson AR. Satisfied patients exiting the emergency department (SPEED) study. Acad Emerg
Med 2002; 9: 15-21.
30. Thompson DA, Yarnold PR. Relating patient satisfaction to waiting time perceptions and expectations: the
disconfirmation paradigm. Acad Emerg Med 1995; 1057-1062.
31. Handel DA, French LK, Nichol J, et al. Associations between patient and emergency department operational
characteristics and patient satisfaction scores in an adult population. Ann Emerg Med 2014; 64: 604-608.
32. Derlet RW, Richards JR. Overcrowding in the nation’s emergency departments: complex causes and disturbing effects.
Ann Emerg Med 2000; 35: 63-68.
33. Slash door to doc time, boost patient approval. Hosp Case Manag 2011; 19: 142-143.
Background
This resolution calls for ACEP to acknowledge that higher patient satisfaction scores are associated with many
indicators of poor quality of medical care, many factors unrelated to medical care and many components of
medical care not under physician control, and to oppose the use of patient satisfaction surveys for physician
credentialing or for emergency medicine financial incentives or disincentives.
In September 2010, the ACEP Board approved the “Patient Satisfaction Surveys” policy statement that outlines
specific elements that should be incorporated into patient satisfaction survey tools. The policy specifically states:
“Due to the difficulty in segregating whether patient satisfaction scores are a result of physician
performance or due to demands and restrictions of the current health care system or other factors out
of the control of the physician, patient satisfaction methods that have not been validated should not be
used for purposes such as credentialing, contract renewal, and incentive bonus programs.”
During the 2010-11 committee year, the Emergency Medicine Practice Committee (EMPC) was assigned an
objective to develop an information paper, “Emergency Department Patient Satisfaction Surveys.” The ACEP
Board reviewed the paper in June 2011. This paper outlines many of the methodological limitations of current
patient satisfaction surveys.
In January 2013, ACEP provided commentsto CMS on ED patient satisfaction survey development in response to
its request for information to aid the design and development of a survey regarding patient experiences with ED
care. The comment letter addresses concerns about weighing the value of patient satisfaction surveys, including
surveys completed by patients admitted from the ED, impact of wait times, questions related to pain control,
sample size and survey mechanism.
In the spring of 2013, ACEP staff and members met with the CMS project officer for ED-HCAHPS and were
informed that CMS has developed three separate instruments to be used for:
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Patients discharged from the ED
Patients admitted to the hospital, stand-alone survey administered separate from HCAHPS
Patients admitted to the hospital, survey conjoined with HCAHPS
CMS is currently testing the three instruments. The Emergency Department Patient Experiences with Care
(EDPEC) Survey is currently under development. The 2.0 version instrument is published here.
Resolution 39(15) Patient Satisfaction Surveys in Emergency Medicine
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ACEP Strategic Plan Reference
Develop and promote delivery models that provide effective and efficient emergency medical care in
different environments.
Fiscal Impact
Budgeted committee and staff resources.
Prior Council Action
Resolution 43(13) Patient Satisfaction Scores referred to the Board. Called for the College to take a clear public
stance to reject the continued use of non-valid patient satisfaction scoring tools in emergency medicine and that
current patient satisfaction surveys should not be used to determine ED physician compensation and
reimbursement.
Resolution 26(12) Patient Satisfaction Scores and Pain Management not adopted. Called for the College to work
with appropriate agencies and organizations to exclude complaints from ED patients with chronic non-cancer pain
from patient satisfaction surveys; oppose new core measures relating to chronic pain management in the ED;
continue to promote timely, effective treatment of acute pain while supporting treating physicians’ rights to
determine individualized care plans for patients with pain; and bring patient satisfaction scores and pain
management to the AMA for national action.
Substitute Resolution 22(09) Patient Satisfaction Surveys adopted. Directed ACEP to disseminate information to
educate members about patient satisfaction surveys including how emergency physicians armed with more
knowledge can assist hospital leaders with appropriate interpretation of the scores and encourage hospital and
emergency physician partnership to create an environment conducive to patient satisfaction.
Prior Board Action
June 2011, reviewed the information paper “Emergency Department Patient Satisfaction Surveys.”
September 2010, approved the policy statement “Patient Satisfaction Surveys.”
Substitute Resolution 22(09) Patient Satisfaction Surveys adopted.
Background Information Prepared by: Margaret Montgomery, RN
Practice Management Manager
Reviewed By: Kevin Klauer, DO, EJD, FACEP, Speaker
James Cusick, MD, FACEP, Vice Speaker
Dean Wilkerson, JD, MBA, CAE, Council Secretary and Executive Director