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Why Do ED Ratings Vary by Hospital Size?

by Rick Blizzard, D.B.A.
Health and Healthcare Editor

Fourth in a series of articles examining the effects of hospital size on patient attitudes.

As discussed in previous articles, Gallup has found that patients' ratings of their satisfaction with, loyalty to, and trust in their hospital varies only marginally by facility size -- but that the greatest amount of variation in that regard occurs in the emergency department. One common explanation for variance in patient perceptions by hospital size is that they are positioned differently: larger facilities are perceived as offering sophisticated technology and specialized services ("high tech"), while smaller facilities are considered to provide more personalized care ("high touch"). But does this explanation fit the variances found in emergency department scores?

The Overall Impact of Facility Size on the Emergency Department

Different questions tapping patients' opinions of their emergency department visit vary differently by facility size. Patient trust, for example, is higher in facilities with more than 200 beds than in smaller facilities, while patient satisfaction is highest in facilities of 100 beds or fewer and lowest in facilities of 400 beds or more. There is little size-based differentiation in emergency department patient loyalty.

How can these variances be explained? The two strongest determinants of emergency department satisfaction are the length of time spent in the emergency department and the sense of urgency shown by ED staff members. These two specific attributes are also among those with the greatest variation by facility size, as are the findings for efficiency and speed of service.

The word "emergency" implies an unplanned and urgent situation. In the emergency department, patients place a premium on speed of service. Hospitals with 100 beds or fewer receive higher satisfaction scores because patients feel they deliver service more quickly than hospitals with 300 beds or more. This is a critical positioning advantage for small facilities.

It should also be noted that perceptions of cleanliness affected by facility size as well. Emergency departments in smaller facilities (100 beds or fewer) are viewed as cleaner than those in larger facilities (300 beds or more).

What About the Staff?

"High touch" positioning is based on the interaction between the patient and the emergency department staff. This interaction can be assessed by attributes such as a staff's helpfulness and courteousness, nurses' abilities to make patients feel safe and secure, and the level of concern shown by the staff. While emergency departments in facilities with 100 beds or fewer have a tendency to score higher on these attributes than those in facilities with 300 beds or more, the variance (.06 or less) is much less than that found in ratings of the speed and efficiency of service. Surprisingly, little variation by facility size is seen among quality ratings of the ED doctor.

Bottom Line

Speed and efficiency of service is the key differentiator between patient satisfaction with emergency departments at small facilities and those at large facilities. That is, patients tend to be more satisfied with the ED in small facilities because the lower volume makes it less likely they will perceive slow service and inefficiency in these facilities.

There is a crisis in the nation's emergency departments, caused by increased patient volume, shortages of inpatient beds, staffing shortages and inadequate physical facilities. The data suggest a need for increased operational improvements in the emergency departments of larger facilities. EDs in small facilities may benefit from positioning themselves as fast and efficient at treating minor illnesses and injuries. Those in large facilities, on the other hand, may be better off emphasizing their ability to deliver world-class care in critical situations. This positioning would have the side benefit of helping maximize the appropriate use of scarce ED resources by giving patients information that helps them better select the type of hospital best suited for their particular situation.


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