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SAMJ: South African Medical Journal

On-line version ISSN 2078-5135
Print version ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.105 n.6 Pretoria Jun. 2015 



Patient satisfaction with emergency departments



To the Editor: The National Department of Health clearly states its mission objective 'to improve quality of care of all levels of the health system is a priority'.[1] The Department also aims to 'improve the overall efficiency of the health care delivery system'. The key words are improvement, quality and efficiency. So, are we all striving towards this objective? Are we all constantly trying to improve the level of service we offer to our patients and to improve their level of satisfaction?

How does a healthcare practitioner know when they are satisfying their patients' needs and their perception of good healthcare? The business world, especially the service industry, does this effectively by routinely conducting customer satisfaction surveys, thereby identifying areas that are lacking. Healthcare practitioners and healthcare institutions should be doing the same.

Measurement of patient perception, no matter how difficult, can be improved via continuously doing patient-orientated surveys to fully understand, effectively manage and then exceed patients' expectations as the ultimate goal.

In 2005, a survey of 40 000 households showed that 65% of respondents identified that both care and compassion are more important than technical proficiency when receiving medical care.[2] Power and associates further conducted a survey which showed that 'satisfaction with the hospital experience was driven (in order of importance) by dignity and respect, speed and efficiency, comfort, information, and communication and emotional support'.[2]

In South Africa (SA), there has been increasing concern regarding the mounting pressures on emergency departments (EDs). Frequent media reports document increases in waiting times, overcrowding and the resulting compromised quality of care in EDs. We recently conducted a survey to determine what the expectations are of a local patient population attending a public sector ED and how happy they are with their care.

As waiting time is a key factor in patient satisfaction in EDs, satisfaction predictably dipped the longer the patient waited. The total time spent in the ED averaged 295, 386 and 451 minutes depending upon the acuity of illness (for orange, yellow and green category patients, respectively), compared with the average time of 247 minutes for all category patients across the USA in 2010.[3] One may be forgiven for thinking that there is not much we can do about the situation in our under-resourced, overcrowded environment, but there are measures that can be implemented.

One effective measure to achieve patient satisfaction is to manage perceptions and expectations of waiting time. Studies have shown that if patients are being informed about the waiting time, they are more satisfied. It is also important to constantly educate our patients that their prolonged wait at a tertiary or secondary institution could have been avoided had they attended a more appropriate clinic or primary healthcare facility.

It is interesting to note that while green-category patients spent an average of 271 minutes waiting to be attended to, the attending doctor required only an average of 24 minutes to take the history, investigate, diagnose and treat the patient. This is surely an argument for instituting fast-tracking of patients, which can be accomplished in a number of ways, two of which have been successfully implemented worldwide. We refer to the introduction of minor injury units (MIUs) in busy EDs. These MIUs can be staffed by advanced nurse practitioners (ANPs), physician assistants (PAs) or clincal associates.

An ANP is defined as a person who focuses on primary care, health assessment, diagnosis and treatment. A PA is North America's equivalent of the ANP. In SA, we have no ANP or PA programme. Heeding this call, the University of the Witwatersrand has instituted the 3-year Clinical Associate Programme, designed to qualify ANPs or PAs. MIUs staffed by ANPs and PAs have been been evaluated very favourably, with patients stating increased satisfaction with the quality of service.[4,5]

From the respondents in our survey, frequent negative comments centred around the level of comfort and security in the waiting room. Cleanliness of the patient toilets also featured prominently. This highlights the point raised earlier that simple, seemingly trivial, measures can vastly improve patient satisfaction.

When previous quality surveys were done, whether a patient spent one hour or four hours in the ED, those who rated the waiting room as 'very poor' in comfort had dramatically lower overall satisfaction with their visit than those who rated the comfort of the waiting room as 'very good'. Hospitals can analyse their patients' comments to find ways to improve the comfort level. Simple interventions such as repairing the air conditioning or replacing the chairs may have a noticeable effect on patients' perceptions of the ED.

A benefit of a patient perception study is that it is simple to perform and easily reproducible in other EDs in different localities to further understand patient needs, as patient requirements will differ in different sociodemographic localities. Similar surveys can also be used to monitor progress in EDs as we strive towards enhancing patient care.

The challenges of prolonged waiting times, under-resourced and overcrowded EDs are intense. However, patients are willing to wait for care as long as they are kept informed about the waiting time and are received by empathetic attending healthcare workers. There is a paucity of research looking at qualitative aspects of patient care in SA - more studies need to be done as we strive towards providing optimal care.

Zeyn Mahomed
Emergency Physician, Far East Rand Hospital, and Division of Emergency Medicine, University of the Witwatersrand, Johannesburg, South Africa

Lee Wallis
Head of the Division of Emergency Medicine, University of Cape Town and Stellenbosch University, Tygerberg, Cape Town, South Africa

Feroza Motara
Division of Emergency Medicine, University of the Witwatersrand, Johannesburg, South Africa



1. Department of Health, South Africa. Strategic Plan. (accessed 13 May 2015)        [ Links ]

2. J. D. Power and Associates. The distinguished hospital program.(accessed 13 May 2015).         [ Links ]

3. Press Ganey and Associates. The 2010 Emergency Department Pulse Report. (accessed 13 May 2015).         [ Links ]

4. Beales J, Baker B. Minor injuries unit: Expanding the scope of emergency provision. Accid Emerg Nurs 1995;3(2):65-67. []        [ Links ]

5. Beales J. Innovation in emergency management: Establishing a nurse practitioner-run minor injuries/primary care unit. Accid Emerg Nurs 1997;5(2):71-75. []        [ Links ]

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