Affordable Care Act’s Emphasis on Patient-centered Care Will Revolutionize EMS

Your ambulance service has been in business for 25 years and has always thought it had a good image in the community. However, recently the receiving hospitals have been contacting your service administrators to “complain” that their patients have been saying some unflattering remarks about crew.

You get called in and told that on a recent call you used some off-colored language and smelled of cigarette smoke. Your supervisor lectures you a bit and says he has to keep a record of it in your file and that future patient, family or hospital complaints may result in disciplinary action or discharge from the service.

As you leave his office, your supervisor adds that your future performance reviews will look closely at your customer service skills and as much as 30% of your performance evaluation (and eligibility for a merit raise) will be based on how your patients feel about the way you treat them. You wonder what’s up and find out other crews have recently received the same message.

“˜What’s Up’ with Complaints?
Those of us fortunate enough to have careers in EMS management have the opportunity to hear customer feedback about how our providers have impacted the patient. A typical hospital complaint from an ED director goes something like this:

“Your ambulance crew responded to the house of a patient brought to our ED last night because the patient was having a heart attack. The crew placed her on the cardiac monitor and diagnosed her bradyarrhythmia as Mobitz Type I second-degree AV heart block. They treated her with transcutaneous pacing and atropine. But, she didn’t appear to be symptomatic as she was normotensive and her SpO2 was greater than 95% on room air. According to recently published clinical guidance, atropine should be administered with caution in asymptomatic patients with suspected myocardial ischemia, as ventricular dysrhythmias can occur, so I’m really concerned about the critical decision-making capabilities of your personnel.”

Raise your hand if you’ve ever received a complaint like that.

Even if you haven’t, you probably know the most common complaint about EMS personnel–whether in the field or the communications/business office–centers around the way your staff member impacted the patient’s experience. And most of the complaints come from the patients or their family members who are all ears while you are caring for or transporting their loved ones.

All too often, the complaints center on things such as:

  • The crew was rude;
  • The crew members didn’t explain what they were doing;
  • The crew members didn’t let me ride in the ambulance with my mom;
  • The business office staff didn’t seem to care that my mom is on a fixed income and wanted to pay her ambulance bill over time; or
  • The person who answered our 9-1-1 call didn’t act like it was an emergency.

So the “what’s up?” is actually the fact that one of the many ways the Patient Protection and Affordable Care Act (ACA) is revolutionizing our healthcare delivery system is by placing significant emphasis on the patient’s experience of care.

Figure 1: HCAHPS Survey Question Examples

HCAHPS Survey Question Examples

Illustration courtesy Centers for Medicaid and Medicare Services


And who cares for and transports the patient to the hospital? You do! The services EMS and transport providers deliver can be a big part of the patient or family’s experience. So, now, all of a sudden, since the hospitals are being “scored” by the government and reimbursement to their facility is being affected by the patient’s “overall experience,” the hospitals are taking a close look at all the personnel involved in the care of the patient to make sure they’re satisfied–no matter what it takes. That’s where it affects EMS.

Hospitals will now have us under the microscope to evaluate not only our care, but also our customer service to “their” patients. In some cases, hospitals have already started buying ambulance services to control this process themselves. In others, they’ve canceled interfacility contracts with ambulance providers and selected another service, or, they’ve decided to start their own interfacility service. Some have even started rotating flight crews off helicopters and onto mobile critical care ambulances once a week.

Patient-Centered Care
The concept of patient-centered care has been around for over a decade, ever since the Institute of Medicine (IOM) identified it as one of the six goals for a 21st century healthcare system.1 However, it wasn’t until the ACA placed financial incentives on the concept that healthcare providers really began to take notice.

Under the ACA, hospitals now receive performance-based bonuses or penalties based on two main measures: 1) Value-based purchasing (VBP); and 2) readmission rates for specific diagnostic related groups (DRGs) like myocardial infarction, heart failure and pneumonia.

The fiscal year 2014 Hospital Value-based Purchasing (HVBP) program links a portion of the hospital’s payment from the Centers for Medicaid and Medicare Services (CMS) to performance on a set of quality measures, which include: the Clinical Process of Care Domain, which accounts for 45% of a hospital’s total performance score (TPS); the Patient Experience of Care Domain, which accounts for 30% of TPS; and the new Outcome Domain, which accounts for 25% of TPS. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is the basis of the Patient Experience of Care Domain.

The HCAHPS survey asks discharged patients 32 questions about their recent hospital stay.2 The survey contains 21 core questions about critical aspects of a patients’ hospital experience, including:

  • Communication with nurses and doctors;
  • The responsiveness of hospital staff;
  • The cleanliness and quietness of the hospital environment;
  • Pain management;
  • Communication about medicines;
  • Discharge information;
  • Overall rating of hospital; and
  • f they would recommend the hospital.3

The HCAHPS survey is mandatory (except for specific critical access hospitals that can choose to voluntarily participate) and is published for public view through the CMS Hospital Compare site at This allows the public to see how a specific hospital’s patient experience ratings compare to other regional hospitals, as well as state and national averages.

The surveys can only be conducted by CMS-approved vendors, or by the HCAHPS organization itself. The most recognized company hospitals contract with for surveying is Press Ganey. Press Ganey has been conducting patient experience surveys for more than 30 years with over 10,000 healthcare clients, and has become the “gold standard” for measuring patient satisfaction. Any hospital administrator will recognize the name.4

Patient satisfaction and experience of care is impacting every aspect of hospital operations. Recently, a group of hospital ED directors formed a task force to address the rising incidence of prescription drug overdoses. One of the strategies proposed to reduce these occurrences was to have all hospitals pledge to refer patients in the ED with chronic pain management issues to specialists instead of prescribing narcotic pain relievers.

One ED physician director commented that the strategy would be a hard sell to ED doctors unless patients seeking pain medications could be classified as “no info” patients, negating the possibility the patient would receive an HCAHPS survey. The concern was that a portion of hospital income is derived from the patient satisfaction scores. If the patients don’t get their pain prescription, they could rate the experience negatively and adversely impact the satisfaction score and the hospital’s income.

As a result of this focus on the patient experience of care, many hospital systems are adding a new C-suite member to their team. They’ve always had positions such as chief executive officer, chief operating officer, chief medical officer and chief nursing officer, but now many will have a Chief Experience Officer (CXO).

Top box scores example

Cleveland Clinic was the first major academic medical center to make patient experience a strategic goal and to appoint a CXO, and one of the first to establish an Office of Patient Experience.5 CXOs don’t typically come from the healthcare industry, but rather from organizations specializing in customer service, such as the Marriot Corporation.

In a July 2013 article in the Los Angeles Times, reporter Anna Gorman chronicled a new initiative underway at San Francisco General Hospital with the addition of a CXO and a director of first impressions:

“Now, patients at San Francisco General Hospital are greeted by a smiling face and a helping hand to guide them along the path to getting care. It’s one of a series of customer-friendly touches being added at the 156-year-old institution by a newly named chief patient experience officer.

“To help make patients feel more welcome, San Francisco General created the position of director of first impressions. An oversized stoplight dubbed the “˜yacker tracker’ was installed next to a nurses’ station that switches to red when noise levels rise too high. Yoga classes for patients and staff have been added and new signs posted to make it easier for people to find where they’re going.”6

Why EMS Should Care
EMS providers need to pay particular attention to this growing focus on patient satisfaction and experience of care for several reasons.

1. Our patients care about what (and how) we care for them.

We typically get zero “points” from patients for the clinical care we provide. Patients assume that since we arrived at their medical emergency in mobile intensive care units when they called 9-1-1, we have clinical expertise. However, we get bonus points from the patient’s perspective when we’re nice to them–when we communicate well and explain everything we’re doing, when we ensure their pain is controlled, when we worry about their pets after we take “their master” to the hospital, or, as happened recently, when the fire crew stays on scene to finish laying the sod the homeowner couldn’t finish because he had chest pain after laying only three pallets.

2. Our payers now care about what we do (and what we say) to the patients.

Our largest healthcare payer is providing bonuses or penalties based on satisfaction scores. It won’t be long before other payers follow suit. In fact, CMS has accelerated using a quality- and outcome-based metrics program for physicians.7

These bonuses and penalties were scheduled to start in 2017, but CMS moved this implementation date to 2016, due in large part to the improvements in patient-centered care and outcomes fostered through the assessment of bonuses or penalties to hospitals based on HCAHPS scores.

EMS benefits are paid through Part B of Medicare, the same part from which physicians are paid. CMS has notified the EMS industry that we’ll be undergoing a review of the ambulance fee schedule this year. On Sept. 24, the Office of Inspector General released its report on the growth in Medicare payments to the ambulance industry between 2002 and 2011. The report places our industry in an interesting position as we move into those discussions with Medicare. If you haven’t read the report, we strongly urge you to do so.8

3. Our healthcare stakeholders (the sending or receiving hospitals) care.

Ask any hospital administrator what their “top-box” HCAHPS scores are for their facility, and they’ll know. The top-box is the most positive response to HCAHPS survey questions.

A top-box response means a patient answered “always” for each of the five HCAHPS composites (communication with nurses, communication with doctors, responsiveness of hospital staff, pain management, and communication about medicines) and two individual items (cleanliness of hospital environment and quietness of hospital environment); “yes” for the sixth composite (discharge information), “9” or “10” (high) for the overall hospital rating, and said they “would definitely recommend” the hospital.

So hopefully by now you realize that EMS has (and will continue to have) an impact on the hospital’s HCAHPS scores. If we aggravate the patient on the way in to the hospital, it may affect the score that patient gives the hospital. Similarly, if we are the last people to interface with the patient as they’re leaving the hospital (discharge home, for example) and we leave a less-than-favorable impression, it may also impact the hospital.

Now you understand that there’s a lot of money on the table when it comes to that 30% bonus or penalty based on HCAHPS scores.

If your agency is looking for a hospital’s business or wants to do something innovative with the hospital, being able to report your “top-box” scores to the hospital’s CXO will help you a lot.

4. It may be one of the only quality metrics we have.

EMS has had a difficult time proving value to the customer. Few peer-reviewed studies prove that because the patient with a fractured ankle, abdominal pain, dislocated shoulder, etc. went to the hospital by ambulance, the patient’s outcome was different than it would be otherwise.

In today’s new healthcare world, we need metrics we can use to prove value to the payer. It’s probable externally conducted and verified patient experience scores may help as part of an overall set of clinical metrics we can use to demonstrate value.

5. We need to bend the perception curve.

EMS is not viewed by our payers or other financial stakeholders as providing medical care. We are viewed as transportation. That’s why we aren’t paid if we don’t transport. Perhaps if we begin to think of ourselves more as healthcare providers, and measure the same factors as healthcare providers (clinical outcomes and patient satisfaction) instead of response times, people will think of us–and pay us as–healthcare providers.

The Challenge for EMS
Historically, we haven’t done a great job measuring the patient’s experience with our services. While many agencies send out customer surveys, these aren’t typically conducted by an outside agency and are most often response cards mailed to patients who come back to the agency.

In-house surveys are better than nothing, but they bring suspicion of bias, as opposed to third-party surveys conducted by an external agency–similar to the way CMS requires the HCAHPS surveys be conducted. It would be much better to have an external agency do the survey, provide us a summary and then benchmark our performance to other agencies.

Several years ago, Bill Gephard from Mobile Health Resources (MHR) in Michigan and others asked Press Ganey to develop a survey for EMS. After several years, however, they weren’t able to convince enough agencies to sign up and Press Ganey lost interest in the project. The company gave the rights to the product to MHR, which continued the work as the EMS Survey Team (EMSST).

Today, under the direction of Gephard, the EMSST provides randomized, externally monitored patient experience scores in an HCAHPS-type format. The surveys are conducted by EMSST and reports are provided to the participating agency, along with measurement comparisons to the 60 other agencies currently participating. A key benefit is that the EMSST results are completely outside the agency’s control, so much like the HCAHPS scores, the data isn’t subject to bias by the reporting agency.

MedStar Mobile Healthcare is one of the participating agencies in EMSST, along with systems like North Shore University/Long Island Jewish Medical Center EMS and Huron Valley EMS. All of an agency’s run data is uploaded monthly to the EMSST, which randomizes the data and sends out the surveys. Gephard reports a survey return rate of 18—20%, which is much higher than the regular HCAHPS return rate of 8—10%.

Each month the agency receives a report that includes all the scores and returned surveys. If a survey raises a red flag, EMSST sends a real-time alert, along with a copy of the survey for immediate follow up.

Employee-level data can also be tracked so agency employees who consistently provide excellent customer service can be rewarded and, of course, those who don’t can receive additional training in customer service and the patient experience concept.

Speaking of Training “¦
Are our field providers, call center personnel and business office staff prepared to deliver exceptional customer service? How much time is invested in teaching customer service compared to how much time we spend teaching how to resuscitate a cardiac arrest victim or how to apply a traction splint? Why is it we spend so much time teaching our people how to do things to our customers, and virtually no time how to do things for our customers? They may apply a traction splint once in their career, but they interact with patients on every call.

Some will say it’s because of the risks posed with low-frequency, high-acuity skills. We could argue the greatest risk we face in our service delivery to a patient is not treating them as a patient or as a customer. Patients will generally forgive a missed IV or a bumpy ride in an ambulance, but it’s harder for them to forgive not being treated with respect.

Thankfully, the National Association of EMTs offers a course on the principles of ethics and personal leadership, which teaches EMS personnel how to make sound ethical decisions, prevent conflict and be EMS ambassadors.9

We’re arguably at the most pivotal time in our young profession. The ACA has provided EMS an unprecedented opportunity to become a part of the healthcare system, a move that many of us have dreamed about for decades. We need to pay attention to the changing dynamics of the environment in which we operate.

The factors that currently impact hospitals, doctors and other healthcare providers will also impact us sooner than we think. Take the time to help shape our future and how we participate in this new healthcare system. It’s time to focus on the patient and the patient’s experience with our service.

Wayne Gretzky said two important things during an interview when he was asked what makes him such a great hockey player. One was, “You miss 100% of the shots you don’t take.” The other was, “A good hockey player plays where the puck is. A great hockey player plays where the puck is going to be. I skate to where the puck is going to be, not where it has been.” Our advice to you is to go ahead, take the shot, get ahead of the other team and focus on improved customer satisfaction sooner rather than later.


1. Committee on Quality of Health Care in America, Institute of Medicine. Crossing the quality chasm: A new health system for the 21st century. National Academy Press: Washington, D.C., 2001.

2. HCAHPS fact sheet. (August 2013.) CAHPS Hospital Survey. Retrieved Dec. 17, 2013, from

3. HCAHPS: Patients’ perspectives of care survey. (April 10, 2013.) Centers for Medicare & Medicaid Survey. Retrieved Dec. 17, 2013, from

4. Transforming the patient experience. (n.d.) Press Ganey. Retrieved Dec. 17, 2013, from

5. Office of patient experience. (n.d.) Cleveland Clinic. Retrieved Dec. 17, 2013, from

6. Gorman A. (July 20, 2013.) Healthcare overhaul leads hospitals to focus on patient satisfaction. Los Angeles Times. Retrieved Dec. 17, 2013, from

7. Rau J. (July 22, 2013.) Medicare announces plans to accelerate linking doctor pay to quality. Kaiser Health News. Retrieved Dec. 17, 2013, from

8. Wright S. (Sept. 24, 2013.) Memorandum report: Utilization of Medicare ambulance transports, 2002—2011. Health and Human Services Office of the Inspector General. Retrieved Dec. 17, 2013, from

9. Principles of ethics and personal leadership. (n.d.) National Association of Emergency Medical Technicians. Retrieved Dec. 17, 2013, from


The Hospital’s Perspective
Kathie Russell, the director of marketing and organizational development at Plaza Medical Center, a Hospital Corporation of America (HCA) facility in Fort Worth, Texas, says her hospital seriously considers a patient’s experience and HCAHPS scored by making patient satisfaction a top priority for HCA’s leadership.

The hospital has implemented several programs to enhance the patient’s experience, including one called “leadership rounding.” Plaza’s top management team regularly walks the hospital visiting patients, staff and visitors to see how they’re doing and find out if there’s anything they can do to enhance their experience at the hospital.

A second program, “quiet time,” is a break in the day, usually late in the afternoon, when all the staff in patient care areas purposefully make the area very quiet.

HCA uses Gallup to conduct its HCAHPS surveys. At Plaza, 1,200 patients a month are randomly selected from all in-patient, out-patient, ED and day surgery discharges to receive telephone surveys from Gallup staffers. Patients agree whether or not to participate in the survey upon their discharge.

When asked the role EMS plays in the hospital’s HCAHPS scores, Kathie said it can be substantial. “EMS is often the first point of contact our patients have with our hospital. If the patient has a bad experience with EMS before arriving at the hospital, it will impact the patient’s perspective of their hospital stay.”

The concept of patient-centered care has been around for over a decade but it wasn’t until the ACA placed financial incentives to the concept that healthcare providers really began to take notice … Are our field providers, call center personnel & business office staff prepared to deliver exceptional customer service?


  • Doug Hooten, MBA, is the executive director at MedStar Mobile Healthcare, the exclusive emergency and non-emergency provider for Fort Worth, Texas, and 14 surrounding cities in North Texas. He's been in EMS for over 30 years serving in executive level management for AMR, Rural/Metro and MAST in Kansas City (Mo.). Doug can be reached at

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