Patient Relations: Your Complete Guide to Patient Service

The first thing he saw was the dead fish.

“If they can’t even keep a fish alive, how are they going to take care of me?” The question, posed by a patient at a practice where consultant Vicki Bradford was conducting a focus group, was asked in jest. But the person who posed it reminded Bradford of a simple truth about patients: They will make clinical decisions based on nonclinical information.

Bradford says you can distinguish yourself from your competitors by sweating the small stuff. “Find out what your patients want and need, and then train your staff to deliver it,” she advises.

How? Just ask them.

Julie Sanderson-Austin, vice president of quality, research, and management at the American Medical Group Association, recommends holding your own informal focus group with an assembly of loyal patients. “Ask them what you can do to make their experience with your practice better,” she advises. “When practices do … they are amazed at how easy the fixes are. Patients really aren’t that demanding. Your patients’ feedback is your best source for determining how you can develop a service-oriented practice.

“Monitoring how patients feel about your services and knowing whether or not they are satisfied with them is just a part of doing business,” says Sanderson-Austin. “And the last time I checked, medicine was still a business.”

Gauging patient satisfaction shouldn’t be a one-time exercise. “It’s an ongoing process that’s never done,” says Bradford. “Some practices think, ‘OK, we’ve completed our survey, and we’re finished.’ But they’re not. They have to do it again to compare their results from previous times to determine if they are performing any better or worse.”

Regardless of whether you hold patient focus groups, offer an online satisfaction survey, or simply hand patients a paper survey with a clipboard and pen, experts agree it’s essential to identify what your patients want and need on an ongoing basis.

For example, Bradford says that one of the most common complaints practices receive from patients is about lengthy wait times. Yet extended wait times are sometimes unavoidable no matter how efficiently you run your practice.

So be creative: Give patients something to do. One group Bradford worked with decided to put a jigsaw puzzle table in its waiting room. The puzzles were such a hit with the practice’s (mostly senior citizen) patients that many started showing up before their appointment times just to work on it. “Sometimes when they don’t have anything to do, they’ll come in without an appointment just to work on the puzzle,” a front-desk receptionist told Bradford.

Another of Bradford’s clients (a group of orthopedists) invested in two electric massage chairs for its waiting room. “The result was that they couldn’t get their patients out of the chairs when the doctor was ready to see them,” she laughs.

And what about those outdated golfing magazines in your waiting room? Do patients really notice them? You bet, says Bradford: “Oddly enough, that’s one thing they consistently pay attention to.” So don’t just bring in old magazines from home; subscribe to publications for your practice that actually would appeal to your particular patient base. They will take note.

Empower your staff

The fact is that many practices are not user-friendly; that is, their patients frequently have to deal with long telephone waits, delayed physician responses, extended periods of time in reception areas, and poorly trained front-desk staff.

Although high-quality patient care should be your practice’s ultimate goal, you’ll have little chance of achieving that if you can’t retain a steady patient base.

So how can you make your patients more satisfied with your services? Like any other business, you must treat them like the valued paying customers they are, and you must reflect that ideal throughout the entire patient experience.

As the physician, you set the tone for your practice’s operations. Your staff will observe your attitude toward patient service and follow your lead. “A really strong service orientation has to start with the physician,” says Susan Miller, the practice administrator for Family Practice Associates of Lexington in Kentucky. “Frankly, I don’t care how many times I tell staff to be nice to patients. If the physicians don’t embody that, if they don’t have that attitude of wanting to help patients, you’re really fighting a losing battle. There needs to be a service orientation that goes all the way to the top.”

And being an effective leader also means knowing when to listen to your staff.

“Leadership has an important job to play, but [physicians are] not necessarily the smartest kids on the block,” says Leonard Friedman, public health professor and the coordinator of Health Management and Policy Programs at Oregon State University. “I may have an MD behind my name, but the people who know the most about scheduling are the people who are sitting behind that front desk.”

You can’t achieve high patient satisfaction when your staff is unhappy. Patients can easily detect the dysfunctional atmosphere bred by a team of quarreling, dissatisfied employees.

“Let’s assume your front-desk receptionist just has an absolutely foul attitude and, although she is very efficient, she is also as mean and nasty as can be,” says Friedman. “What’s going to be the word among your patients? Well, they’re not going to be very happy when they walk in, and I suppose some of them are going to tell their friends that this particular clinic has a real problem with its staff. And there’s the potential that some patients may vote with their feet and find another physician group in town. The actions and activities of your lowest-paid employee could have significant financial repercussions on the larger practice, and even on the livelihood of your physicians.”

One of the most effective ways to keep your staff happy is to give them the autonomy they need to do the jobs you hired them to do. Miller says that her 10-physician group empowers its staff to suggest policies and procedures to their supervisors. Processes are developed by the people who actually carry them out.

But even then, says Miller, you have to trust your staff enough to allow them to bend the rules if necessary. “Our attitude is that we are here to take care of patients,” says Miller. “It’s a simple philosophy: Do what you need to do to make that happen. I usually tell staff that our policies and procedures are guidelines, but if they think it’s necessary to go around a rule to properly take care of a patient, then by all means they have permission to do that.”

Bradford also tells her physician clients to empower their staff to solve problems as they arise in their own departments. For example, the front-desk staffers at one pediatric practice were frustrated that harried parents often resisted, or even refused, to hand over their insurance cards at check-in (on the grounds that the request was an unnecessary nuisance).

So the staff brainstormed and came up with a game. Receptionists distributed small cards to incoming patients with 15 punch holes. Each time a parent checked in and handed over her insurance card without being asked for it, she earned a hole punch. Once the card had been punched 15 times, the parent’s child “won” a Beanie Baby.

“The parents were coming in the office and even before the door closed behind them, they were pulling out their insurance cards and waving them,” says Bradford. “It became a fun game for both parents and the front-desk staff, and it almost wiped out their insurance card problem.

“My advice is always to be creative and hand problems over to the people who have to handle that situation and see what they can come up with,” says Bradford. “Those on the front lines are often the best resources.”

Providing a total patient service experience means paying close attention to each part of the patient visit, from the time a new patient calls your office for an appointment until that patient checks out after the visit. This process can be broken down into five distinct elements, each of which presents an opportunity for your staff to either maximize patient service or to disappoint and alienate patients. They are:

1. Previsit information gathering. Sanderson-Austin says the gold standard in this area is to adequately prepare the patient before she enters the office so that both she and the practice already have all of the information they need for the visit by the time the patient walks in. “Access is the No. 1 complaint patients voice about their office visit experiences,” says Sanderson-Austin. “And by ‘access,’ I mean that patients are not just able to simply get an appointment when they call, but that they are able to see the specific physician they want to see in the time frame they want to see him, and not have to wait beyond that time in the reception area.”

That’s not a problem for Terrence McAllister, a pediatrician in Plymouth, Mass. McAllister often answers his own office phone, something that surprises his new patients and downright startles pharmacists, nurses, and other physicians. Such easy access is the aspect of his practice that draws the most kudos from his patient base. “They love that I answer the phone or that I call them right back,” says McAllister.

How does he do it? For one thing, he has to. Performance Pediatrics’ only other staffer is Leann DiDomenico, the practice’s administrative director.

Technology is essential for McAllister to provide such personalized service. With his fully implemented EMR, his year-old practice is automated and paperless. The practice’s Web site is very comprehensive, incorporating insurance information; downloadable registration, health history, and adolescent health forms; FAQs about the practice; links to helpful sites for parents and children; a monthly e-newsletter that patients can opt to receive; and more.

McAllister encourages new patients to go to his Web site before their office visits to familiarize themselves with his practice and to download and complete the necessary forms in advance. He says that about half of his patients have their completed forms in hand when they arrive. “Patients really do like it,” says McAllister. “If they have a toddler they have to keep an eye on while filling out paperwork in the office, it’s difficult. If they can do that at home, when the child is asleep, it makes it a whole lot easier. And I get more thorough information that way as well. They have time to think about things like family history, talk to their spouses about it, and give me more information.”

After an appointment is scheduled, DiDomenico verifies the patient’s insurance online and collects any copay upfront. McAllister greets his patients himself and escorts them to one of his three age-appropriate exam rooms. (He has separate rooms for infants, children aged 2-12, and teenagers.) His office’s wireless network makes it easy for him to tote around his tablet PC, which he says is no more intrusive than a pen and clipboard.

Miller’s much larger Family Practice Associates of Lexington (FPA) averages about 300 patient visits daily. But the practice’s Web site, where patients can download all necessary forms and even complete and submit them online if they choose, enables FPA to offer optimal service right from the start. Patients can also request appointments and prescription renewals online, get self-care information, and learn general background about the practice, its physicians, and its policies. “We find that if we can drive patients to our Web site right at the beginning of their experience, then they’ll know what’s there and feel more comfortable with us,” says Miller. “We get uniformly positive feedback from our patients regarding our online services.”

But regardless of how many features your Web site may have, it’s only effective to the extent that your patients know about it and use it. When surveyed patients gave Miller’s practice low scores on their wait time, she knew the group could move through office visits much faster if more patients took advantage of their Web site’s capabilities.

“Frankly, we hadn’t done a good job educating our staff about what our site offered,” says Miller. So she held educational sessions in which she guided staff members through the site and its offerings. “Some of our staff had never been to our Web site and really had no idea what was there.” Once employees were more comfortable talking to patients about the site and its capabilities, surveyed patients began indicating positive experiences with their wait time.

Finally, always keep in mind that when a new patient calls, the person who answers is her very first contact with your practice, and it’s essential that that person is courteous, helpful, well-informed, and respectful. This may seem self-evident but it’s surprising how often practices make this staff person their lowest priority - hiring teenagers with no professional experience and poor social skills, and then giving them little or no training.

Paula Comm, practice administrator for PRA Behavioral LLC, a psychiatry practice in Schaumburg, Ill., says that when she is training new staff, she uses a “mystery shopper” service that calls new employees and poses as a patient. Later, the “shopper” reports back to Comm on her new hire’s performance. “When someone is making that first call for a psych appointment, you need to understand just how difficult it is for them,” explains Comm. “Regardless of how unclear they may be, you have to have 10 times more patience when taking that call because it was so difficult for the patient to make it.”

2. Front-desk intake procedures. “Check-in is no longer a warm, fuzzy experience,” says Miller. “Today, it’s ‘I need to get all of this information about you, it needs to be accurate, we need to know what your insurance is and get all of those details now so we can get you in to see the physician as quickly as possible.’”

If not well-monitored, Miller says the typical check-in process becomes a push-and-pull between the front and back desks. “They want the patient’s information in the back as quickly as possible because they want to get the patient roomed and stay on time, and then I’m putting all kinds of pressure on the front desk to get accurate billing information so we can make sure we get paid for the visit,” Miller explains.

Of course, patients entering an office may be ill, irritated at having to take time off from work, anxious about impending test results, or worried about their loved ones. So they’re usually not at their best when they approach the registration desk. “We talk a lot about how not to take things personally,” Miller says.

“Patients say what they want is immediate acknowledgement,” adds Bradford. “When they walk in the door, someone should engage them in eye contact, even if they are on the phone. A simple smile can say, ‘I see you, I’m glad you’re here, and I’ll get to you in a moment.’ That all can be communicated nonverbally. It’s one of the most important interactions you will have with that patient that day.”

3. Patient greeting and exam. Another vital patient-service experience occurs when the patient is called into the back office. “Often a patient has been waiting a long time and is growing anxious,” says Bradford. “When his name is called, he becomes very nervous. It’s a time when the nurse or assistant receiving the patient can best help counteract those feelings and make the patient feel more at ease.”

Most often, when patients are taken into a practice’s back office, they make several stops before they are shown into an exam room: one place to get weighed, another to have their temperature and blood pressure taken, and perhaps a third to talk to a nurse about their presenting illness and health history. Sanderson-Austin says that although traditional physical plant issues support this game of “room tag,” research has shown that taking a patient into a single exam room complete with all of the equipment necessary to take and record the patient’s vital signs boosts both office efficiency and patient satisfaction. “It’s the new model that practices are striving to develop,” she says.

McAllister says his one-stop exam room model has been very well received by his patients and their parents. “As I do their vital signs and take their histories, the kids and their patients get a chance to warm up to me,” he explains. “They don’t feel like they’re telling their story seven or eight times to different people and never really getting anywhere, so I think my model simplifies things greatly.”

McAllister even administers vaccines and draws blood himself if needed. Everything is done in the same room. He has the capability to do some simple lab work, such as rapid strep tests and urine strips in the office; for more complex work, he contracts with a lab.

McAllister says that doing all of these procedures himself allows him to spend more time with individual patients. Since he currently sees eight to 12 patients a day, he says he doesn’t feel rushed through appointments. Indeed, the most positive feedback he’s received has been on the amount and quality of the time he spends with patients and parents. “They’re able to ask a lot of questions, and I’m able to make sure that they really understand what I’m saying. … It helps because in the long run it saves me time on the other end because there are fewer questions that come up later that night.”

4. Patient check-out procedures. McAllister’s “one-stop-shopping” model also includes check-out procedures that are performed in the exam room. If any prescriptions are warranted, he sends them electronically to the local pharmacy. He schedules any follow-up appointments, and his EMR reminds him if the child is due in the near future for vaccinations or well-baby visits that he also schedules on the spot. Finally, for baby visits, McAllister prints out a growth chart for the parent.

To ease check-out procedures at her large practice, Miller says that her check-in and check-out staff are part of, and report to, the billing team. “Once or twice a year we do a major billing and access team meeting in which we talk about all billing aspects because it’s all tied together,” she explains. Having this know-how allows front-desk staff to knowledgeably explain charges to patients who come to them with questions.

Another convenience Family Practice Associates of Lexington offers its patients is the opportunity to fill some of their prescriptions at check-out. The group stocks a small formulary of acute episodic drugs. Patients really appreciate the convenience of not having to go to a pharmacy after their visit. And so does the staff. “It’s not something that involves scheduling or coordinating appointments or collecting money,” explains Miller. “They kind of get involved in the patients’ care.”

Keep in mind that the person who checks out your patients is the last face they will see before leaving the office. “If they are treated well, they’ll feel like they are leaving a group of friends, people who will welcome them when they return,” says Bradford. But she also cautions managers to tell their check-out staff to choose their words wisely when talking to departing patients. “Be careful when asking questions like, ‘Did everything go all right today?’” she says. “For some patients, it may not have.”

5. Follow-up. For most patients, their care continues long after their appointment with you. They need prescriptions, lab work, X-rays, scans, tests, and referrals. Keeping track of patients once they leave the office is “probably the hardest thing we do,” says Miller. Her group is in the process of transitioning from a document management system to an EMR, and Miller hopes that will ease their follow-up procedures. Her office currently tracks all referrals by recording the date and time a patient is scheduled to see a specialist and then follows up to ensure the appointment was kept. If not, her staff contacts the patient to determine why not, and does its best to “close the circle of service” by ensuring the patient receives referred care.

I can’t get no …

Patient satisfaction is easy to take for granted. But you don’t want to wait until your phone stops ringing before you think about patient attraction and retention.

“Physicians really need to look at how patients want to be treated in the nonclinical part of their experience in a medical practice,” says Bradford. “They’ve got to understand the uniqueness of their customer population and their setting. So details are key.”

Amidst the hustle and bustle of everyday practice, it may be easy for you to miss a floating dead fish in the tank in your reception area. But your patients won’t.

Barbara A. Gabriel, MA, is the associate editor of Physicians Practice. She has served as editor and writer for numerous healthcare publications during the past 10 years. Barbara can be reached at bgabriel@physicianspractice.com.

This article originally appeared in the March 2008 issue of Physicians Practice.