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Increase of ER Visits with Short Staff Creates Decrease in NPS Scores

Patient-experience scores have taken a rollercoaster ride throughout the COVID-19 pandemic, bucking average trends and creating mystery around what’s genuinely impacting the patient experience—until now.

In the early stages of the pandemic, scores experienced a boost, likely due to the “healthcare heroes” phenomenon, in which appreciation for healthcare workers soared. Scores then appeared to even out to the pre-pandemic normal until February 2021, when a decline in the Net Promoter Score in the emergency-department care setting was noticed, first dropping from 49 to 48 from February to March, and then to 39 in July 2021.

While nationally, U.S. hospitals have faced staffing shortages amid the latest wave of COVID-19 infections, NRC Health’s Mid-Year Consumer Trends Report shows that patients are no longer delaying care and are returning to healthcare at meaningful rates. NRC Health’s Real-time Feedback, which measures patient-experience data, supports this by showing an increase in emergency-department patient volume, with more than 40% more visits from February to July of 2021. Plotting patient volume next to NPS shows a relationship between the two factors.

“They were definitely understaffed. The ER was packed. They were kind but did not have time to spend on any one patient.”
Michigan ER patient

Staffing Impact Not Slowing Down

Sarah Fryda, Senior Research Associate with NRC Health, says this impact—especially in emergency departments across the country—is particularly concerning.

In Florida, Arkansas, Louisiana, Oregon, Texas, Tennessee, and Idaho, the influx of patients now resuming services has been met with a shortage of healthcare workers, exacerbated by the trauma and burnout associated with working through the COVID-19 pandemic.

Tennessee is sending members of its National Guard to some hospitals to help fill staff shortages amid the COVID-19 surge. According to the Florida Hospital Association, nearly 70% of Florida’s hospitals are expecting critical staffing shortages in the next week. The Associated Press reports that Florida’s largest medical provider has lost nurses to staffing agencies, other hospitals, and pandemic burnout. Some nurses are lured away for jobs in other states at double or triple their salary. The Texas governor directed state officials to use staffing agencies to find additional medical staff beyond the state’s borders as the Delta variant overwhelms its present staffing resources.

“While not all patients realize staffing shortages in healthcare, they notice how these shortages impact their experiences,”
Sarah Fryda, Senior Research Associate, NRC Health

Negative mentions of wait times and responsiveness significantly increased from February to July 2021 for emergency departments. Negative sentiment around wait times increased by 13%, and negative remarks on responsiveness increased by 11%. In total, these types of overall increases of negativity coincide directly with the increase in volume and the decrease in Net Promoter Score.

“The nurse and doctor were sympathetic to my condition but did not take positive or timely steps to relieve my pain. I was discharged with essentially no improvement in my condition. My subsequent visit to a different ER resulted in much better outcomes and course of treatment.”
—Colorado patient

Patient Care Pays the Price

Fryda says the patient experience is not the only thing that suffers when healthcare systems struggle with staffing and an increased volume of patients—patient care also suffers. NRC Health also found an increase in alerts—high-priority comments that warrant immediate follow-up in the emergency department—from 22% to 26%, a net increase of 4%, from February to July 2021.

Every alert type outside of mental-health alerts increased from February to July 2021 in emergency departments, with clinical error alerts rising at 2.2% and negative experiences following close behind at 2.1%.

“We wish follow-up would have been more efficient. We didn’t get informed of lab results as quickly as possible, and we were sent home still with a lot of questions unanswered.”
—Arizona patient

Rising Alerts in Post-discharge Care

Deficiencies in patient care can also be tracked in NRC Health’s Care Transitions data, which measures post-discharge calls. Alerts citing deficiencies have increased recently in the emergency department, increasing 8% from 25% in February to 33% in July 2021.

Like comment alerts, every care transition alert category experienced an increase from February to July 2021 among patients receiving discharge phone calls in the emergency department. The types of issues patients raised alerts about included satisfaction with the quality of care, which increased by 4%, and questions about follow-up care or care instructions, which increased by 2.7%.

Four Ways NRC Health Clients Addressed Burnout

In an attempt to address the burnout rate (which was high even before COVID-19 hit), Sutter Health leaders in Sacramento anticipated it getting worse during the stress of the pandemic and, via their Joy of Work team, brought on hospital leads for the program right when the hospital staff needed it.

One of the first things they focused on was physicians’ mental health, especially given the demands of COVID-19. To do that, they contracted with each hospital to host an Employee Assistance Program and give physicians access to free and confidential assessments, short-term counseling, referrals, and follow-up services.

Sutter Health also offered one-to-one peer support—physician to physician—for those experiencing a tough time. “It could be potentially a complicated case with a patient, a difficult interaction, an outcome that was unexpected, for example,” says Jill M. Kacher Cobb, MD, anesthesiologist and leader of the Joy of Work well-being team at Sutter Health. “Maybe they have stress at home, a sick parent, a sick child, a real loss. We advocated so everyone knew they could reach out for peer support and talk to someone.”

Lastly, they knew not everyone would be comfortable going to somebody within their organization for peer support, so they put together helpful courses offered locally and nationally, along with other well-being resources to support their workforce.

“We were able to find some people passionate about wellness and help them set up wellness committees,” says Cobb. “I think that having that touchpoint at each facility and knowing that there was a focus on physicians’ wellness helped to begin to change our culture.”

This critical timing, along with partnership with NRC Health, allowed Sutter Health to survey their workforce to find out what else they needed from their organizations and their leadership during COVID-19. They learned that their workforce needed to be heard, cared for, and valued.

Delivering Patient-care Information Differently

Destinee Carrington, Nurse Project Manager at Children’s Hospital Los Angeles, worked on virtual focus groups to gain parent feedback and creatively engage staff to improve in the areas parents of patients shared about most.

“It was incredible because we were short-staffed, and we were dealing with all the things people dealt with during COVID-19,” Carrington says. “The staff was dealing with personal pain and still coming in every day and going above and beyond.”

Carrington says that this year, she knew she had to be more creative in sending out the information. She also knew that her staff were overloaded with information: emails, new education around COVID-19, and changing protocols. She also knew that if staff satisfaction wasn’t high, then they wouldn’t be in a place to receive any kind of feedback.

“I’m a nurse at heart,” Carrington says. “I remember what it felt like to be completely giving everything you have, working yourself to your last bit of energy, and feeling like you don’t have the energy to participate in a project or engage with other things.” Knowing that many staff members felt utterly tapped out, she wanted to find a way to give them constructive feedback without making them feel defensive. “I knew that if we wanted this feedback to be meaningful, we had to figure out a way to give it to them in a meaningful way.”

Carrington decided to create a menu, which included “Shareables”—items parents enjoyed when they were done efficiently and consistently—“Main Courses,” which included NRC Health survey items that parents asked for improvement on, and “Desserts,” which were direct quotes and compliments for best practices and division units.

She emailed the feedback menu to all clinical services staff, and to ensure staff read it, she added an incentive to respond. Lastly, after reviewing the menu, Carrington communicated to all team members who replied with the items that affected them and what they would improve upon. All staff members who responded to the email put their names into a drawing to receive one of six Starbucks gift cards. This method of engaging the staff was a huge success, and led to them sharing and brainstorming ideas individually and improving as a team.

Focus on Human Understanding

The focus group is only one of many tactics Carrington has employed in the Cancer and Blood Disease Institute at Children’s Hospital Los Angeles that have been replicated in other hospital areas. She has created and deployed multiple educational sessions on high-priority patient-experience items like AIDET and the teach-back method, and helped ambulatory clinics make “Who to Call, When to Call” documents to help parents easily reach the correct staff member when they return home.

What Carrington has learned is that listening without being defensive brings simplicity to the care she is able to give.

“When you walk in at the beginning of the day and asking a patient or family, “Is there anything that I can do today to make you have a great day?” that makes a big difference,” she says. “Although it may take an extra five minutes of conversation, you know what’s important to them already at the start of your shift. You can address that all day long, and they already know, from the onset, that you’re on their side. Otherwise, sometimes you can be battling them. They don’t think that you care for them, and it causes more issues.”

Based on this approach, CBDI created “What’s Your One Thing?” posters to facilitate communication between staff and families. Carrington said they found out that they could answer 100 questions, but if staff didn’t answer the one question a patient truly needed answered, the patient might come away saying that their questions hadn’t been answered. “Just those small conversations help the family understand that you care about them more than just getting them in and out of there,” Carrington says.