ORIGINAL CONTRIBUTION
Evaluation of an Emergency Department Patient Advocacy Program Maria Salmon White, Sc D Geoffrey Gibson, PhD Baltimore, Maryland
In the Patient Advocacy Program at the Adult Emergency Department of The Johns Hopkins Hospital, first year medical and health associate students provide patient teaching, crisis intervention, emotional support, assistance in patientprovider-family communication, resource referrals, information and assistance in maintaining patients' rights. The advocacy program was evaluated through a three-month trial of a Control Group, Patient Advocacy Group, Halo Group and Placebo Group, including 412 study subjects in all. It was hypothesized that patients' satisfaction, behavior and knowledge would improve significantly as a result of the advocate's intervention in this order: Patient Advocacy, Halo, Placebo and Control. Patient interviews and medical records were used to assess the impact of patient advocacy. Results did not support the hypotheses of either improvement or the ranked order. Competition with traditional roles, identification of advocates with providers rather than patients, and placing the needs of the institution over patients were suggested as explanations for the advocacy program's failure. White MS, Gibson G: Evaluation of an emergency department patient advocacy program. JACEP 7:145-148, April 1978.
patient advocacy, emergency department, evaluation.
INTRODUCTION
In 1973, the Adult Emergency Department at the Johns Hopkins Hospital founded its Patient Care Liaison Program to improve patient-provider communication and patient and family satisfaction. As a second program objective, students served in the patient care liaison role as part of their required course of study. After evaluating one year's experience with the Patient Care Liaison Role, the emergency department administration decided that the liaison function had improved patient satisfaction, 1 but was too limited in other respects. Thus, the Patient Advocacy Program grew out of the Patient Care Liaison Program by adding two further objectives: 1) raising levels of patient ~kn0wledge about their condition and care, and 2) improving patient compliance with their regimen and referral after their emergency department visit. The paOent advocate role included patient teaching, crisis intervention, emotional support, assistance in patient-provider-family communication, resource referrals, information and assistance in maintaining patients' rights. For From the Health ServicesResearch and DevelopmentCenter, Departmentof EmergencyMedicine, The Johns Hopkins Universityand Medical Institutions,Baltimore, Maryland. Presented at the UniversityAssociation for Emergency Medicine Annual Meeting in Kansas City, Missouri, May 1977. Supported in part by Grant No. HS 01907 from ~e National Center for Health Services Research, DHE-W, to the Health Services Research and Development Center, The Johns Hopkins Medical Institutions, Baltimore, Maryland. Address for reprints: GeoffreyGibson, PhD, 624 N. Broadway, Baltimore, Maryland21205. 7:4 (Apr) 1978
JACEP
145/35
the most part, advocates were first year medical and health associate students who spent 16 hours d u r i n g t h e school y e a r b e i n g t r a i n e d a n d s u p e r v i s e d in t h e i r advocacy functions. The s u p e r v i s o r s were second y e a r s t u d e n t s who h a d successfully completed t h e i r s t u d e n t advocacy exp e r i e n c e a n d w e r e s e l e c t e d for e m p l o y m e n t as p a r t - t i m e s u p e r visors, This study ~ e v a l u a t e s the Pat i e n t Advocacy P r o g r a m of the J o h n s Hopkins Emergency D e p a r t m e n t according to its objectives of improving p a t i e n t knowledge, satisfaction and behavior.
HIGH
PATIENT KNOWLEDGE
Patient Advocacy ..i
gJ >
Halo
METHODS
The s t u d y design, a c o n t r o l l e d t r i a l c o n d u c t e d in J u n e , J u l y a n d A u g u s t of 1975, c o m p a r e d four exp e r i m e n t a l groups: 1) Control Group -- neither directly nor indirectly e x p o s e d to a p a t i e n t a d v o c a t e or placebo e x p e r i m e n t a l t r e a t m e n t ; 2) P a t i e n t Advocacy Group - - directly interacted with a patient advocate during the emergency department visit; 3) Halo Group - - v i s i t e d the e m e r g e n c y d e p a r t m e n t w h e n a pat i e n t advocate was on duty, but had no direct interaction, and 4) Placebo G r o u p - - e x p o s e d to a v o l u n t e e r w e a r i n g the uniform of a p a t i e n t advocate and i n s t r u c t e d to ~'chat a n d be friendiy" w i t h patients. The p e r i o d s d u r i n g w h i c h t h e p a t i e n t groups were exposed to the varying experimental conditions were stratified by month, day of the week and shift. Over the threem o n t h period, the Control Group was observed for the first month, the Pat i e n t Advocacy and Halo Group the second m o n t h and the Placebo Group the third month. For each study m o n t h (defined as four consecutive seven-day periods), each day of the week was replicated twice to control for differences in p a t i e n t volume and characteristics and to assess different i a l advocacy impact by day of the week. Work shifts were also used for further stratification so that, for each month, there were two cases for each shift for each day of the week. The 412 s t u d y s u b j e c t s w e r e s e l e c t e d a c c o r d i n g to t h e i r a r r i v a l t i m e in the e m e r g e n c y d e p a r t m e n t (no e a r l i e r t h a n 30 m i n u t e s after the b e g i n n i n g a n d no l a t e r t h a n 90 minutes before the end of a work shift), age (between 18 and 65 y e a r s of age inclusive), condition (lacerations and puncture wounds, exclusive of gunshot w o u n d s a n d s t a b wounds; abd o m i n a l pain; lower l i m b i n j u r i e s , not including lacerations; upper limb 36/146
Control
Placebo
LOW GROUPS
KEY: - levels hypothesized - levels
Fig. 1, Hypotheses and findings on patient knowledge. No significant variations between groups were found. HIGH
PATIENT SATISFACTION
Patient Advocacy ¢D ..I IJ,I > U.I
Halo
._1
Placebo
Control LOW GROUPS
Fig. 2. Hypotheses and findings on patient satisfaction with the emergency department. Significant variations were found between groups. JACEP
7:4 (Apr) 1978
PATIENT DEPARTURE
HIGH
Patient Advocacy
Halo ,-I g,J
> U,I ,-I
Placebo
Control
LOW GROUPS
Fig. 3. Hypotheses and findings on patients leaving prior to completion of treatment. No significant variations between groups were found.
visit and before the follow-up or return appointment. A similar written questionnaire was sent to those patients not available by telephone. Patient e m e r g e n c y d e p a r t m e n t and o u t p a t i e n t billing records yielded patient behavior information, including frequency of patients leaving the emergency department prior to completion of treatment and compliance with follow-up and return visit appointments. The study hypothesized that patients' satisfaction, behavior and knowledge would improve significantly as a result of the advocate's intervention in the order shown (Figures 1 to 5). It was hypothesized that, for all three characteristics, the Patient Advocacy Group would demonstrate the highest levels of satisfaction, the Halo Group the second highest, the Placebo Group the third highest and the Control Group the lowest level, while exhibiting similar levels of behavior and knowledge as the Placebo Group. RESULTS
HIGH
PATIENT COMPLIANCE - - ONE APPOINTMENT
Patient Advocacy Halo
¢/) .J UJ
> uJ ..i Placebo
Control
LOW GROUPS
Fig. 4. Hypotheses and findings, on patient compliance with appointment (patients with one appointment). No significant variations between groups were Found.
injuries, not including lacerations; and chest pain) and not being admitted to the hospital. Study patients were also required to have either a return or follow-up appointment related to their emergency department visit. Patient interviews and medical 7:4 (Apr) 1978
records were used to assess the impact of patient advocacy. A pretested telephone interview regarding patient knowledge about his condition and care, as well as measures of patient satisfaction, was administered to each of the four study groups within two weeks after the patient JACEP
The study findings indicated g e n e r a l lack of support for both hypotheses. There were no significant differences between the study groups with respect to patient behavior and patient knowledge (Figures 1 to 5). There was, however, a significant difference between groups in p a t i e n t satisfaction with the emergency department. Unexpectedly, it was the Placebo, rather than the Patient Advocacy Group, that reported g r e a t e s t satisfaction. The Placebo, rather than the Patient Advocacy Group indicated highest patient knowledge while the Control Group was second highest, and the Halo Group third. The lowest level of knowledge was found, quite surprisingly, in the Patient Advocacy Group. The highest level of satisfaction was found in the Placebo Group while the Patient Advocacy Group had the second highest level. The third and fourth highest levels were exhibited by the Halo and Control Groups respectively. Behavior, m e a s u r e d t h r o u g h three separate items - - leaving before completion of treatment, compliance with first appointment in those p a t i e n t s with only one appointment, and compliance with first appointment in those patients with two appointments - - was the only characteristic for which the Patient Advocacy Group exhibited the highest level. 147/37
PATIENT COMPLIANCE - - TWO A P P O I N T M E N T S
HIGH
Patient Advocacy (/) ..J LIJ
The final possible explanation comes from the fact t h a t the program was i n s t i t u t i o n a l l y s p o n s o r e d a n d c o n s t r a i n e d . I n h e r e n t in t h i s and other similar inpatient programs cited in the l i t e r a t u r e ( C u t t i n g red tape and the hospital. S u n Papers, Baltimore, A p r i l 20, 1975) 3,4 is the tendency, if not necessity, to place t h e n e e d s of t h e i n s t i t u t i o n over those of the patient. If t h i s is, indeed, the case, t h e n it is u n l i k e l y t h a t such p a t i e n t - c e n t e r e d objectives as those espoused by t h e advocacy p r o g r a m will be successful.
Halo
> LU .J
Placebo
Control
LOW GROUPS
Fig. 5. Hypotheses and findings on patient compliance with appointment (patients with two appointments, who kept only one). No significant variations between groups were found. DISCUSSION According to this study, the Pat i e n t A d v o c a c y P r o g r a m f a i l e d to m e e t i t s o b j e c t i v e s of i m p r o v i n g levels of p a t i e n t knowledge, satisfaction and behavior. There are several possible e x p l a n a t i o n s for this. W i t h i n the role definition of the advocate, there m a y be e l e m e n t s of competition with other traditional roles. For example, teaching and
38/148
c o m p e t e w i t h a n d d e t e r f r o m the prQvider-patient role. It is also possible the advocates t h e m s e l v e s identified more strongly w i t h providers than patients, an o r i e n t a t i o n to be expected in h e a l t h profession students. While the advocacy role m a y have been of benefit to students, it seems to have lacked benefit for patients.
emotional support have been historically assigned p r i m a r i l y to the nurse. In t h e p r e s e n c e o f t h e a d v o c a t e , nurses m a y abrogate these functions r e s u l t i n g in lower r a t h e r t h a n h i g h e r levels of p a t i e n t knowledge. The success of the placebo over the p a t i e n t advocate may indicate that the placebo r a t h e r t h a n the advocate role facilitates the p r o v i d e r - p a t i e n t role and t h a t the advocate role m a y well
JACEP
REFERENCES
1. Linzer M, Whitmore J: The Social Impact of the Patient Advocate on an Emergency Room. The Johns Hopkins Hospital Department of Emergency Medicine, May 1977. 2. White MS: Evaluation of an Emergency Department Patient Advocacy Program, thesis. Division of Health Care Organization, Johns Hopkins University School of Hygiene and Public Health, 1977. 3. Ravich R, Rehr H: Omsbudsman program provides feedback. Hospitals 48:6368, 1974. 4. Snook DI Jr: Patient's rights. Hospitals 48:177-180, 1974.
7:4 (Apt) 1978
Evaluation of an Emergency Department Patient Advocacy Program Maria Salmon White, Sc D Geoffrey Gibson, PhD Baltimore, Maryland
In the Patient Advocacy Program at the Adult Emergency Department of The Johns Hopkins Hospital, first year medical and health associate students provide patient teaching, crisis intervention, emotional support, assistance in patientprovider-family communication, resource referrals, information and assistance in maintaining patients' rights. The advocacy program was evaluated through a three-month trial of a Control Group, Patient Advocacy Group, Halo Group and Placebo Group, including 412 study subjects in all. It was hypothesized that patients' satisfaction, behavior and knowledge would improve significantly as a result of the advocate's intervention in this order: Patient Advocacy, Halo, Placebo and Control. Patient interviews and medical records were used to assess the impact of patient advocacy. Results did not support the hypotheses of either improvement or the ranked order. Competition with traditional roles, identification of advocates with providers rather than patients, and placing the needs of the institution over patients were suggested as explanations for the advocacy program's failure. White MS, Gibson G: Evaluation of an emergency department patient advocacy program. JACEP 7:145-148, April 1978.
patient advocacy, emergency department, evaluation.
INTRODUCTION
In 1973, the Adult Emergency Department at the Johns Hopkins Hospital founded its Patient Care Liaison Program to improve patient-provider communication and patient and family satisfaction. As a second program objective, students served in the patient care liaison role as part of their required course of study. After evaluating one year's experience with the Patient Care Liaison Role, the emergency department administration decided that the liaison function had improved patient satisfaction, 1 but was too limited in other respects. Thus, the Patient Advocacy Program grew out of the Patient Care Liaison Program by adding two further objectives: 1) raising levels of patient ~kn0wledge about their condition and care, and 2) improving patient compliance with their regimen and referral after their emergency department visit. The paOent advocate role included patient teaching, crisis intervention, emotional support, assistance in patient-provider-family communication, resource referrals, information and assistance in maintaining patients' rights. For From the Health ServicesResearch and DevelopmentCenter, Departmentof EmergencyMedicine, The Johns Hopkins Universityand Medical Institutions,Baltimore, Maryland. Presented at the UniversityAssociation for Emergency Medicine Annual Meeting in Kansas City, Missouri, May 1977. Supported in part by Grant No. HS 01907 from ~e National Center for Health Services Research, DHE-W, to the Health Services Research and Development Center, The Johns Hopkins Medical Institutions, Baltimore, Maryland. Address for reprints: GeoffreyGibson, PhD, 624 N. Broadway, Baltimore, Maryland21205. 7:4 (Apr) 1978
JACEP
145/35
the most part, advocates were first year medical and health associate students who spent 16 hours d u r i n g t h e school y e a r b e i n g t r a i n e d a n d s u p e r v i s e d in t h e i r advocacy functions. The s u p e r v i s o r s were second y e a r s t u d e n t s who h a d successfully completed t h e i r s t u d e n t advocacy exp e r i e n c e a n d w e r e s e l e c t e d for e m p l o y m e n t as p a r t - t i m e s u p e r visors, This study ~ e v a l u a t e s the Pat i e n t Advocacy P r o g r a m of the J o h n s Hopkins Emergency D e p a r t m e n t according to its objectives of improving p a t i e n t knowledge, satisfaction and behavior.
HIGH
PATIENT KNOWLEDGE
Patient Advocacy ..i
gJ >
Halo
METHODS
The s t u d y design, a c o n t r o l l e d t r i a l c o n d u c t e d in J u n e , J u l y a n d A u g u s t of 1975, c o m p a r e d four exp e r i m e n t a l groups: 1) Control Group -- neither directly nor indirectly e x p o s e d to a p a t i e n t a d v o c a t e or placebo e x p e r i m e n t a l t r e a t m e n t ; 2) P a t i e n t Advocacy Group - - directly interacted with a patient advocate during the emergency department visit; 3) Halo Group - - v i s i t e d the e m e r g e n c y d e p a r t m e n t w h e n a pat i e n t advocate was on duty, but had no direct interaction, and 4) Placebo G r o u p - - e x p o s e d to a v o l u n t e e r w e a r i n g the uniform of a p a t i e n t advocate and i n s t r u c t e d to ~'chat a n d be friendiy" w i t h patients. The p e r i o d s d u r i n g w h i c h t h e p a t i e n t groups were exposed to the varying experimental conditions were stratified by month, day of the week and shift. Over the threem o n t h period, the Control Group was observed for the first month, the Pat i e n t Advocacy and Halo Group the second m o n t h and the Placebo Group the third month. For each study m o n t h (defined as four consecutive seven-day periods), each day of the week was replicated twice to control for differences in p a t i e n t volume and characteristics and to assess different i a l advocacy impact by day of the week. Work shifts were also used for further stratification so that, for each month, there were two cases for each shift for each day of the week. The 412 s t u d y s u b j e c t s w e r e s e l e c t e d a c c o r d i n g to t h e i r a r r i v a l t i m e in the e m e r g e n c y d e p a r t m e n t (no e a r l i e r t h a n 30 m i n u t e s after the b e g i n n i n g a n d no l a t e r t h a n 90 minutes before the end of a work shift), age (between 18 and 65 y e a r s of age inclusive), condition (lacerations and puncture wounds, exclusive of gunshot w o u n d s a n d s t a b wounds; abd o m i n a l pain; lower l i m b i n j u r i e s , not including lacerations; upper limb 36/146
Control
Placebo
LOW GROUPS
KEY: - levels hypothesized - levels
Fig. 1, Hypotheses and findings on patient knowledge. No significant variations between groups were found. HIGH
PATIENT SATISFACTION
Patient Advocacy ¢D ..I IJ,I > U.I
Halo
._1
Placebo
Control LOW GROUPS
Fig. 2. Hypotheses and findings on patient satisfaction with the emergency department. Significant variations were found between groups. JACEP
7:4 (Apr) 1978
PATIENT DEPARTURE
HIGH
Patient Advocacy
Halo ,-I g,J
> U,I ,-I
Placebo
Control
LOW GROUPS
Fig. 3. Hypotheses and findings on patients leaving prior to completion of treatment. No significant variations between groups were found.
visit and before the follow-up or return appointment. A similar written questionnaire was sent to those patients not available by telephone. Patient e m e r g e n c y d e p a r t m e n t and o u t p a t i e n t billing records yielded patient behavior information, including frequency of patients leaving the emergency department prior to completion of treatment and compliance with follow-up and return visit appointments. The study hypothesized that patients' satisfaction, behavior and knowledge would improve significantly as a result of the advocate's intervention in the order shown (Figures 1 to 5). It was hypothesized that, for all three characteristics, the Patient Advocacy Group would demonstrate the highest levels of satisfaction, the Halo Group the second highest, the Placebo Group the third highest and the Control Group the lowest level, while exhibiting similar levels of behavior and knowledge as the Placebo Group. RESULTS
HIGH
PATIENT COMPLIANCE - - ONE APPOINTMENT
Patient Advocacy Halo
¢/) .J UJ
> uJ ..i Placebo
Control
LOW GROUPS
Fig. 4. Hypotheses and findings, on patient compliance with appointment (patients with one appointment). No significant variations between groups were Found.
injuries, not including lacerations; and chest pain) and not being admitted to the hospital. Study patients were also required to have either a return or follow-up appointment related to their emergency department visit. Patient interviews and medical 7:4 (Apr) 1978
records were used to assess the impact of patient advocacy. A pretested telephone interview regarding patient knowledge about his condition and care, as well as measures of patient satisfaction, was administered to each of the four study groups within two weeks after the patient JACEP
The study findings indicated g e n e r a l lack of support for both hypotheses. There were no significant differences between the study groups with respect to patient behavior and patient knowledge (Figures 1 to 5). There was, however, a significant difference between groups in p a t i e n t satisfaction with the emergency department. Unexpectedly, it was the Placebo, rather than the Patient Advocacy Group, that reported g r e a t e s t satisfaction. The Placebo, rather than the Patient Advocacy Group indicated highest patient knowledge while the Control Group was second highest, and the Halo Group third. The lowest level of knowledge was found, quite surprisingly, in the Patient Advocacy Group. The highest level of satisfaction was found in the Placebo Group while the Patient Advocacy Group had the second highest level. The third and fourth highest levels were exhibited by the Halo and Control Groups respectively. Behavior, m e a s u r e d t h r o u g h three separate items - - leaving before completion of treatment, compliance with first appointment in those p a t i e n t s with only one appointment, and compliance with first appointment in those patients with two appointments - - was the only characteristic for which the Patient Advocacy Group exhibited the highest level. 147/37
PATIENT COMPLIANCE - - TWO A P P O I N T M E N T S
HIGH
Patient Advocacy (/) ..J LIJ
The final possible explanation comes from the fact t h a t the program was i n s t i t u t i o n a l l y s p o n s o r e d a n d c o n s t r a i n e d . I n h e r e n t in t h i s and other similar inpatient programs cited in the l i t e r a t u r e ( C u t t i n g red tape and the hospital. S u n Papers, Baltimore, A p r i l 20, 1975) 3,4 is the tendency, if not necessity, to place t h e n e e d s of t h e i n s t i t u t i o n over those of the patient. If t h i s is, indeed, the case, t h e n it is u n l i k e l y t h a t such p a t i e n t - c e n t e r e d objectives as those espoused by t h e advocacy p r o g r a m will be successful.
Halo
> LU .J
Placebo
Control
LOW GROUPS
Fig. 5. Hypotheses and findings on patient compliance with appointment (patients with two appointments, who kept only one). No significant variations between groups were found. DISCUSSION According to this study, the Pat i e n t A d v o c a c y P r o g r a m f a i l e d to m e e t i t s o b j e c t i v e s of i m p r o v i n g levels of p a t i e n t knowledge, satisfaction and behavior. There are several possible e x p l a n a t i o n s for this. W i t h i n the role definition of the advocate, there m a y be e l e m e n t s of competition with other traditional roles. For example, teaching and
38/148
c o m p e t e w i t h a n d d e t e r f r o m the prQvider-patient role. It is also possible the advocates t h e m s e l v e s identified more strongly w i t h providers than patients, an o r i e n t a t i o n to be expected in h e a l t h profession students. While the advocacy role m a y have been of benefit to students, it seems to have lacked benefit for patients.
emotional support have been historically assigned p r i m a r i l y to the nurse. In t h e p r e s e n c e o f t h e a d v o c a t e , nurses m a y abrogate these functions r e s u l t i n g in lower r a t h e r t h a n h i g h e r levels of p a t i e n t knowledge. The success of the placebo over the p a t i e n t advocate may indicate that the placebo r a t h e r t h a n the advocate role facilitates the p r o v i d e r - p a t i e n t role and t h a t the advocate role m a y well
JACEP
REFERENCES
1. Linzer M, Whitmore J: The Social Impact of the Patient Advocate on an Emergency Room. The Johns Hopkins Hospital Department of Emergency Medicine, May 1977. 2. White MS: Evaluation of an Emergency Department Patient Advocacy Program, thesis. Division of Health Care Organization, Johns Hopkins University School of Hygiene and Public Health, 1977. 3. Ravich R, Rehr H: Omsbudsman program provides feedback. Hospitals 48:6368, 1974. 4. Snook DI Jr: Patient's rights. Hospitals 48:177-180, 1974.
7:4 (Apt) 1978
