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  Home > Our Publications > Strategic Health Care Marketing > Featured Article
Want Big Rewards?
Focus on Customer Service
in the Emergency Department

by Susan Solomon

If your hospital is intent on improving customer service, start with the emergency department. That’s the word from many health care consultants, who recommend an ED transformation before all else.

“Between 15 percent and 50 percent of ED patients become inpatients at most hospitals,” says Stevan Bosanac, director of marketing for EMPATH, a health care consulting firm in Richmond, CA. “It just makes sense to concentrate on customer service in the ED.”

Health care marketers have long known that ED marketing can help raise slumping hospital volumes. But the strategy fell out of favor a few years ago when many EDs became overwhelmed with patients and service problems.

The pendulum has swung again. Administrators and marketers now recognize that EDs still provide an attractive revenue stream, particularly when there are charges for imaging and other services. The secret to ED success today is a customer service transformation.

Health care consumers are becoming more demanding about their care and have little tolerance for traditional ED treatment, which often meant long wait times and dingy waiting rooms. As a result, hospitals are working hard to increase customer satisfaction and create patient-friendly EDs, which ultimately result in better word-of-mouth marketing, increased employee satisfaction, and growth in hospital volumes.

Customer service strategies

Customer service strategies for the ED run the gamut from offering paramedics refreshments to providing more luxurious waiting rooms and patient areas. Some hospitals have invested significantly in private ED rooms with solid doors and walls (no curtain separations), indirect lighting, windows to let in sunlight, and private television with cable and VCR capabilities. Other EDs offer playrooms and babysitting services. Then there are those that have experimented with valet parking and even dog walking services.

Most hospitals intent on improving customer care have worked hard to reduce bureaucracy and eliminate seemingly redundant processes. Some hospitals have introduced procedures wherein patients are not merely triaged and told to sit in the lobby if their condition does not prove serious enough for immediate attention. Instead, nurses greet all patients, help them complete registration, and personally direct them to the appropriate next step in the care continuum.

Still another tactic is addressing the needs of the moderately ill who cannot get to primary care physicians. Although minor care programs for less serious illnesses are commonplace, Oakwood Healthcare System in southeast Michigan made the service more specific during flu season. The system offers patients same-day or next-business-day appointments with primary care physicians through its ambulatory health centers network. The program has proved highly popular with local residents.

Surveying patients after they receive treatment is also considered important for customer satisfaction. Key areas of concern are wait times (i.e., time to see a nurse and/or a physician), information provided upon discharge, and the performance of housekeepers, laboratory and radiology technicians, and other employees. If the patient is admitted, the time spent waiting for a hospital bed becomes critical.

Building relationships
Some hospitals invest considerably in enhancing customer service for potential referral sources. It is not uncommon to have a physician liaison regularly visit primary care physicians and other specialists who are key drivers to the ED. The liaison typically discusses new ED services and familiarizes the doctor and office staff with ED personnel.

Reaching out to emergency personnel, such as paramedics and emergency medical technicians, has also proved successful. Many larger hospitals provide special lounges stocked with food and beverages for paramedics. One hospital regularly brings aptly named “hero” sandwiches to paramedics at their fire stations as an acknowledgement of their courageous work.

The waiting game
Of all the customer service strategies employed by hospitals, none has proved as effective as reducing ED wait times, which have become noticeably longer at most hospitals. According to the Centers for Disease Control and Prevention, the average wait time for non-urgent visits increased between 1997 and 2000 by 33 percent, from 51 minutes to 68 minutes.

One of the pioneers of guaranteed ED wait times is Oakwood Healthcare. It promises patients they will see a doctor within 30 minutes or they receive free movie tickets and a written apology from the department.

Before the program was implemented, all indicators pointed to an emergency care system that was hemorrhaging. The average length of stay for ED patients not admitted as inpatients was nearly seven hours. For admitted patients, the average length of stay ranged from eight to 14 hours. The average wait time for triage, registration, and physician evaluation exceeded 90 minutes. Staff morale was low, ambulances were diverted because beds were full, patients left before being seen, and physicians were reluctant to refer patients to Oakwood’s ED.

Tom Worobec, Oakwood’s director of communications, says implementing the program required a year of preparation to study all processes and disciplines that contributed to treating ED patients. One of the first steps was for all players to realize they would not be able to significantly improve the emergency patient experience until they stopped thinking of emergency care as solely the responsibility of ED personnel. Instead, they began to view themselves as an emergency care system that required services and support from almost every hospital department. A comprehensive study of the patient care experience resulted in changes not only in the ED, but also in the departments that work closely with the emergency staff, including radiology and laboratory services.

One of the most significant changes was patient registration. Patients are now asked only five simple questions (name, address, age, Social Security number, and reason for visit) upon arrival. Insurance payment information is obtained later.

The numbers easily justify the program, which was piloted at Oakwood’s Dearborn facility in 2000 and soon afterward implemented at all of the system’s hospitals. Oakwood recorded more than 201,000 emergency visits in 2002 versus 164,000 in 2000. Oakwood also saw its market share in Dearborn and surrounding areas grow by 4 percentage points in two years.

Worobec reports that employee satisfaction has also improved. Staff members are more focused on customer service and, ultimately, have more pride in their work.

Initially, Oakwood weathered criticism, including a comparison to a promotion by a pizza restaurant chain that promised delivery in 30 minutes or less. But many hospitals across the country have found success with similar wait time guarantees. For example, Northern Nevada Medical Center in Sparks, NV, promises patients they will be seen by a nurse within 15 minutes of arrival or the emergency department visit is free. With the help of an aggressive ad campaign, the hospital has seen a 54 percent increase in patient volume since the initiative began. Other hospitals have even upped the ante with a 15/30 guarantee, meaning that the patient is guaranteed to see a nurse within 15 minutes of arrival and a doctor within 30 minutes.

The one-minute challenge
Not surprisingly, Oakwood’s 30-minute guarantee caught the attention of competing hospitals. In April 2004, Sinai-Grace Hospital in Detroit introduced a 29-minute wait time guarantee. So did its sister hospitals Detroit Medical Center, Huron Valley-Sinai Hospital, and Michigan Orthopaedic Specialty Hospital. Conrad Mallett, Sinai-Grace’s president, admits shaving off a minute was intended to counter Oakwood. Worobec of Oakwood says his system is “flattered that other hospitals have adopted the strategy,” although he adds, “We’re not consumed by the one-minute difference.”

Mallett says that implementation of the guarantee has significantly helped his hospital. As he explains, Sinai-Grace, which is located in a highly populated area of Detroit, was losing popularity with the suburban market. “We had to reintroduce our hospital to communities that were turning away from us. The best way to get people back was to focus on service excellence.”

With one of Detroit’s busiest EDs, administrators at Sinai-Grace knew that offering a wait time guarantee was a bit risky. However, after observing Oakwood’s success with the program, the hospital decided it was important to win back patients. Patients not seeing a doctor within 29 minutes would receive tickets to either the New Detroit Science Center, the Charles H. Wright Museum of African American History, or a Detroit Tigers game.

Sinai-Grace’s marketing department promoted the guarantee with radio advertisements, direct mail, and a series of billboards proclaiming, “Lose the Wait at Sinai-Grace” and “Now You No Longer Have to Wait to See Michigan’s Best Doctors.” (Interestingly, another competing hospital countered all the wait time guarantees with a billboard featuring an edgy pitch: “In an Emergency Do You Want Fast – Or Good?”)

Overall, hospital ED doctors responded favorably to the guarantee and promotional campaign. “This is an ER doctor’s dream come true,” says Brooks Bock, MD, who headed Detroit Medical Center system’s emergency services and has since been named president of the system’s Harper University Hospital and Hutzel Women’s Hospital. “When we are able to see patients quicker, it not only allows us to intervene on their behalf more quickly, it also makes the patients and their families happy.”

Ultimately Sinai-Grace failed to make a significant impact on its suburban communities, but the guarantee did dramatically increase volumes. “We didn’t get the population we expected,” reports Mallett. “However, many people in our own area gave us a second look and we made big gains in our primary service area.”

Mallett says the guarantee has had a ripple effect throughout the ED and the hospital. For example, the average length of stay in the ED went from 11 hours to just five.

More wait time tactics
In many areas, wait time guarantees can still be employed as differentiating tactics. Scottsdale (AZ) Healthcare Osborn uses its wait time guarantee to encourage more area residents to bypass competing hospitals for its ED. A prominent billboard in the downtown area promises commuters, “Shorter Wait Times, Faster Care.” The campaign came after the hospital’s ED expansion and resulting increase in capacity.

Robert Wood Johnson University Hospital in Hamilton, NJ, reduced its wait times to 15 minutes for a nurse and 30 minutes for a doctor. The initiative helped win the hospital the Malcolm Baldrige National Quality Award – a highly coveted differentiating factor for any organization.

Other hospital systems are using wait times to drive minor care patients to other facilities in the organization. This is the tactic used by five Mountain States Health Alliance hospitals in northeast Tennessee. Visitors to the Mountain States Web site can receive a real-time report of wait times at the hospitals’ EDs. (Regular updates include the proviso that wait time reports are approximations and only show the amount of time people have been in the waiting room, not the number of patients arriving by ambulance.)

Administrators at Mountain States say they post the ED wait times because four of the five hospitals are within a 30-minute drive of one another. “We want people to know they have a choice of ERs,” says Judy Ingala, RN, chief nursing officer.

Although the hospitals have not seen a significant increase in overall volumes since posting wait times in February, ED staff members note that the effort has helped patients self-triage. Those that are experiencing more minor health concerns are more apt to travel to the ED with the shortest wait times. As a result, the system has experienced some shift of volume from the trauma center to the hospitals that provide lower levels of care.

Perhaps the biggest challenge is getting patients to refer to the information on the Web site, notes James Watson, communications representative at Mountain States. Although local reporters have taken note, the system believes it will require some time for community members to regularly check the site before heading off to the ED.

Silencing the doubters
Although some hospital administrators still question ED marketing as an invitation for overcrowding, more believe that it is a necessity – and a good place to begin customer service initiatives. EMPATH’s Bosanac says his company has definitely seen an increase in requests for assistance with process improvement and customer service in hospital EDs.

The adage about the emergency room being the front door still rings true, Bosanac says. “Word-of-mouth spreads quickly about the way people are treated in the ER, and if the word is positive, increased revenues usually follow.”

Susan Solomon is vice president of corporate communications and marketing for MemorialCare Medical Centers in Southern California. In addition, she is a faculty member at the University of California, Irvine. You can reach her at


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