Are They Smiling?

When a young, female OB/GYN launched her practice, the middle-class Chicago suburb she chose already had its fair share of physicians just like her. But while others had incomes at the median established by the Medical Group Management Association, her income was consistently in the 90th percentile.

How did she do it? After deciding to focus on meeting the needs of women and families, and minimizing the number of managed-care patients she saw, the physician built a practice culture that stressed achieving patient satisfaction. She made sure that everyone -- from the receptionist and billing clerk, to nurses and medical assistants -- understood and bought into this approach.

Serving patients was more than idle talk. The physician developed measurable goals, strategies, and tactics. Every staff member, for example, learned each patient's name, as well as relevant details such as children's ages. Staff answered phones by the third ring. Whenever the physician ran late, staff initiated an appointment-management protocol.

Surveys revealed that patients were pleased with the care they received. Specifically, they reported that the physician always seemed to listen to them, answer their questions, and make them feel special. Economic benefits came in the form of higher patient revenues.

You may think her experience is unique. But simply put, practices that want to be successful focus on patient satisfaction. Practices that reap the rewards of patient satisfaction are driven by physicians who not only understand its importance, but who are also willing to develop a culture to support the strategy.

If you think patient satisfaction is unimportant, consider this: a national online poll of 2,267 adults indicates that patients value physicians' interpersonal skills more than their training.

Insurers such as Aetna now distribute millions of patient satisfaction surveys, giving capitated physicians' bonuses up to 3 percent, depending on the results.

Even superstars such as the Cleveland Clinic aren't resting on their laurels. Through a program called World Class Service, the group mails out some 20,000 patient satisfaction surveys annually. Patients rate their experience from registration to discharge, while teams review the results to identify top issues. Teams focus on top sources of dissatisfaction, develop improvement plans, and work toward better meeting patient needs.

Education and buy-in are key

To start the process of measurement, monitoring, and program development, build physician and management support for patient satisfaction through education. Share information that relates patient satisfaction to physician compensation and practice success. Remember that this is a concept that transcends medicine, and relate stories from name brands and the world of retail shopping. Lexus, for example, uses Gallup to survey 100 percent of its car buyers. High levels of customer and employee loyalty have given Lexus higher margins per car, as well as lower operating costs.

Make a presentation to all physicians within the practice, and be sure to address why patient satisfaction matters. Also explain that patient satisfaction is a process, not some panacea or magic elixir, and relates to how the practice is doing overall.

Pull together a steering committee of formal and informal physician leaders, the practice director, billing office manager, and staff. Plan to meet no less than once a month to develop the patient satisfaction program and measure progress toward goals.

What, and how, to measure

Consider doing your own survey if money is tight. Especially important are three variables: explanations of medical procedures and tests, personal interest in the patient and his/her medical problems, and availability of convenient appointment times. Use a scale of poor, fair, good, very good, and excellent.

Specifically, design your survey to elicit answers to the following questions:

• How satisfied are you with the practice?
• Did the doctor spend enough time with you?
• Did the doctor answer all of your questions?
• Would you recommend the doctor to others?
• How would you rate the number of days you had to wait for an appointment?
• How long did you wait to see the physician beyond the scheduled appointment time?

You may wish to purchase a survey tool, as some sold by national firms permit you to compare your findings to other practices. More sophisticated (and thus costly) surveys help to identify critical scores that influence patient loyalty, retention, and referrals to friends and family.

Vendors include Press Ganey (www.pressganey.com/products_services/) and NRC+Picker (http://nrcpicker.com/Default.aspx?DN=3,1,Documents).

A Web-based system for rating physicians can be found at www.drscore.com.

Or you may want to consult the work done by not-for-profit RAND organization, at www.rand.org/health/surveys/patientdesc.html.

The American College of Physicians also has a tool that is free to members, at www.acponline.org/pmc/new_satis.htm.

Other medical groups have tools available for purchase, including the American Medical Group Association (www.amga.org/QMR/PSAT/index_psat.asp), and the Medical Group Management Association (www3.mgma.com/ecom/store/index.cfm).

Plan to survey approximately 50 to 100 of your patients in a small practice, and up to 400 patients within a large practice. Many practices have discovered that they can achieve response rates of 75 percent if they distribute surveys while patients are in the waiting room, or after patients have settled their bill. If you choose a mail-back survey, build in a reminder system.

Act on survey findings

All too often survey results end up in desk drawers. Instead, make it a point to share your results with physicians and staff. Use a presentation as a platform to launch service improvements.

Avoid the temptation to measure and re-engineer every practice problem area. Instead focus on those factors -- the high dissatisfiers -- that correlate with patient loyalty, recommendations, and referrals. Also make sure that factors under review align with the practice's strategic goals.

Schedule follow-up meetings where the steering committee and other interested parties identify problems, redesign the process, and explore implementation and communication of new designs, as well as measurement and monitoring.

For example, if a practice learns that patients are unable to understand their bills, it can initiate a process to redesign the bills or develop a guide on how to better understand bills.

If patients always have to wait for the physician to arrive, the practice can launch a new protocol requiring staff to tell patients why a physician is late, as well as offer periodic updates on the physician's arrival time. It might even dictate that the practice "compensate" waiting patients with refreshments or a pager.

Making changes can pay off. Through a patient satisfaction survey, a large Chicago practice learned that its front desk failed to adequately meet patient requests for lab results, medical records, and understandable financial statements. Phones were rarely answered by staff members, and even when they were, patients were typically put on hold.

Further analysis conducted by the practice's patient satisfaction team revealed that staff members had little experience and training in functions such as customer service, telephone protocols, and problem resolution. Moreover, staff faced conflicting requests to handle telephone calls, check in patients, and schedule appointments.

Staff positions were upgraded, wages increased $1 an hour, and employees were offered training in how to address service issues. A centralized call center was created to handle pre-visit insurance verification and registration, and reminder calls were made 24 hours prior to an appointment. Finally, the practice launched open-access scheduling that allowed patients to schedule appointments as quickly as possible.

As a result of these service innovations, the goal of answering within three rings was met 88 percent of the time, up from 78 percent. And patient complaints about the front desk dramatically decreased.

Making changes stick

Be aware of barriers to improved patient satisfaction. Some physicians may attack the concept as too "touchy-feely," time-consuming, or costly. Still others may feel stung by low personal scores, patient revisit rates, or anecdotes from disgruntled patients. If this is the case, it helps to compare a physician's scores to those of other physicians and explain why the scores call for action. Then consider appointing a mentor or buddy to work with the physician in identifying problems and solutions. Physicians will respond - especially if you offer them practical tools and techniques.

Integrate patient satisfaction into everyone's job evaluation, with consequences imposed for lack of improvement. Larger practices may want to establish minimum patient satisfaction scores, as well as minimum improvements required to receive bonuses or raises. For example, if the practice's registration area scores in the 50th percentile in a survey, you may want to establish a goal of reaching the 70th percentile within one year.

But make sure that staff members understand the reasons behind their low scores, as well as the importance of a workable improvement plan. Also offer coaching and mentoring so staff can realize their goals.

Consider sending physicians who fail to respond to low scores to a seminar on customer service. In the same way, evaluate staff sensitivity to patient satisfaction issues by observing their interaction with patients, and then addressing scores and patient comments.

Work with staff to develop specific objectives, and reinforce simple strategies such as looking directly at the patient, speaking his or her name, and physically directing the patient to other areas of the practice when necessary.

Remind staff of their goals and accomplishments. Commit to patient satisfaction by making sure staff, physicians, and key managers walk the talk. Make patient satisfaction a top practice priority, not one more project du jour.

Jeff Peters is president of Health Directions, LLC, of Chicago. A frequent national speaker and expert in the financial and operational improvement of hospital-affiliated physician groups, physician group practices, MSOs, academic medical centers, and hospitals, his work focuses on the alignment of governance, organizational resources, and financial incentives. He can be reached at jpeters@healthdirections.com or editor@physicianspractice.com.

This article originally appeared inthe May 2005 issue of Physicians Practice.