Many Hospitals. One Voice. Hospital Care from a Patient Perspective May 2008 Issue Brief available at:

Many Hospitals. One Voice. A Patient’s Perspective A trip to the hospital can be overwhelming to a patient. Hospitals have increasing demands placed upon them at the same time that resources diminish. Providing excellent patient care in this environment can be a challenge. This challenge leads one to wonder, “What is patient care truly like for the patient?” Frank, a hypothetical, typical patient helps answer that question.

Many Hospitals. One Voice. Frank’s Story Late one evening Frank, the generally upbeat protagonist of this story, stumbles in his driveway while taking out the trash. He ignores his aching ankle until the next morning when he finally decides to head to the ER. Frank is tired because the pain in his ankle left him tossing and turning all night. Frank is hungry because he did not eat before he came to the emergency room.

Many Hospitals. One Voice. In the ER Waiting Area Frank Notices: It takes longer than he expected to be triaged and then called to a room There are other people there who are called ahead of him despite their arriving after him The waiting area is crowded Some of the people in the waiting area do not seem all that sick No one stops to check on him during his wait The nurses and staff appear very busy

Many Hospitals. One Voice. Once in His Room in the ER Frank: Waits a long time to see the physician assistant (PA) Feels frustrated because no one brings him food when he tells them he is hungry Receives lab work, a system review, an order for X-rays, and pain medication Is surprised to learn he will need surgery for his unstable fracture Grapples with the possibility that his accident will affect him for the rest of his life

Many Hospitals. One Voice. Frank’s Surgery The orthopedist on call agrees to add Frank’s case at the end of his scheduled cases –Frank waits several hours to be assessed by the orthopedist who sees him between scheduled cases –After his assessment he waits again until the orthopedist finishes the rest of his cases No available beds in the short-stay area means Frank waits for his surgery in the ER Frank is released after a 23-hour observation He is exhausted and irritable after two sleepless nights and the stress of his ordeal

Many Hospitals. One Voice. Factors Contributing to Frank’s Experience Wait Time Staff –Nurses –Allied Health Professionals –Physicians Administrative and Regulatory Responsibilities –For the Patient –For the Hospital

Many Hospitals. One Voice. Wait Time Wait Time is on the Rise –Time spent in the ER before release or admission grew to 3.7 hours or 222 minutes in 2005 –Only 15 percent of patients visiting the emergency department in 2005 were seen in 15 minutes –Time it took to see a physician increased by 36 percent between 1997 and 2004

Many Hospitals. One Voice. Overcrowding Leads to Increased Wait Time Source: American Hospital Association: Results from 2006 Survey of Hospital Leaders

Many Hospitals. One Voice. Reasons for Overcrowding in ED: Inability to transfer patient to an inpatient bed after decision to admit because no available beds exist –Leads to “boarding” in the ER Use of ED as primary source of routine medical care –Hospitals must treat all patients to comply with EMTALA laws –Often used by people who are uninsured because they cannot be turned away

Many Hospitals. One Voice. Wait Time in Northeast Ohio The Center Studying Health System change –Conducted site visits of EDs across the country in 12 cities –Concluded that Northeast Ohio hospital patients moved through EDs faster –Concluded that added space, renovations and greater efficiency enabled Cleveland hospitals to fare so well

Many Hospitals. One Voice. Staff Nurses Allied Health Professionals –For example: Physical therapists CT technologists Radiology technologists Physicians

Many Hospitals. One Voice. Nursing Challenges National nursing shortage Increasing demands and responsibilities placed upon nurses –Taking over for colleagues called away –Managing multiple patients –Filling out paperwork –Conducting satisfaction surveys –Serving on special committees

Many Hospitals. One Voice. Allied Health Challenge National allied health provider shortage –Allied health turnover and vacancy rates are actually higher than that of registered nurses when averaged for the 12 most in-demand professions. CHA member hospitals reported 204 vacant allied health positions in a 2004, fourth-quarter survey. This equates to an 8.9 percent vacancy rate.

Many Hospitals. One Voice. Physician Challenges Typically, physicians operate as independent agents at hospitals –Physicians who practice by their own rules in their home practices must conform to the established culture of the hospital when they are there EMTALA –Physicians report an average of $138,000 in lost revenue as a result of EMTALA –This lost revenue makes some physicians reluctant to work in the hospital at all

Many Hospitals. One Voice. Administrative and Regulatory Responsibilities For Patients –Quick Registration –Once in their emergency department room Full registration information gathered Insurance Co-payment if possible

Many Hospitals. One Voice. Administrative and Regulatory Responsibilities For the Hospital –Documentation must satisfy many entities including federal, state and local government as well as independent accreditation organizations. –There are over 30 different entities involved in hospital regulation at the federal level alone. –Ensuring that care is properly documented for the complex web of entities requires careful and diligent charting by all members of the healthcare team.

Many Hospitals. One Voice. Patient Care to Paperwork Ratios Source: American Hospital Association. “Patients or Paperwork: The Regulatory Burden Facing America’s Hospitals.”

Many Hospitals. One Voice. Frank’s Story: Part Two Frank has now been at home for two weeks Frank waits for his bills –He receives four “your insurance company has been billed” statements –He receives four EOBs –He receives four bills

Many Hospitals. One Voice. Hospital Billing Is More Complex than Other Billing Scenarios The person receiving service is not the sole party responsible for payment –Medicare/ Medicaid –Private insurance Trip to the hospital not one service but several –Hospital or facility charge –Ancillary charges –Physicians, specialists, other healthcare providers

Many Hospitals. One Voice. Billing: The Hospital’s Perspective Nurses, physicians and other providers keep diligent records of care provided to ensure proper billing The chart is given to a medical coder –Reviews record and assigns codes –Submits information in correct format to different payers

Many Hospitals. One Voice. Conclusion When patient expectations diverge from the true hospital experience patients can feel frustrated. Understanding how and why care is delivered the way it is leads to more positive patient experiences. Hospitals are doing their part –Patient education on Web sites –Signs in hospital waiting rooms –Brochures –Patient advocates