Patients Incognito

Want to find out what your practice looks like to the outside world and how well it fares in the increasingly important realm of customer service? Consider hiring a "mystery patient" to tell you what you need to know.

The practice of hiring mystery patients - a concept borrowed from the retail sector, in which specially trained "mystery shoppers" pose as customers for the purpose of evaluating a business' employees and service standards - is becoming increasingly common in healthcare. While hospitals have used mystery patients for many years, the concept began emerging in medical practices only about a decade ago.

Often, the mystery patient comes into the picture after patient satisfaction surveys yield undesirable results, when a merger or split has wreaked havoc, or when a practice wants to assess whether a training effort or new service standards are bearing fruit. Today, practices concerned about competitive positioning or simply seeking to improve processes are using the self-assessment approach to obtain objective, valuable information about what goes right - or wrong - when patients move through a typical visit cycle.

"There are a lot of things practices could fix for themselves, but they just don't see their [business] with the same kind of critical eye because everyone is so busy," says Andrea Eliscu, president of Medical Marketing Inc. of Orlando, Fla., and a former ICU nurse. A trained mystery patient can provide that objectivity, Eliscu says, as well as details on where and how the system breaks down or fails to provide solid - and friendly - service.

"I tell practice owners that the reason to do this is to see if everything you believe is happening when you're not with the patient, is the way it's designed to be," says Eliscu, author of the recently published book, Ready, Set, Market!

mystery patients - typically either specialized consultants or actual patients hired and trained by consultants - go through an entire visit cycle, from making an appointment and being examined to paying the bill and scheduling a follow-up. Their focus is on the service issues, rather than on clinical quality issues, although the two may overlap over the course of the visit. The best mystery-patient firms are able to not only assess the practice but also to provide a detailed report and, if necessary, a follow-up presentation and staff training.

How do you do?

Dermatology Specialists Inc. of Vista, Calif., uses mystery patients on a regular basis in its five north-county San Diego locations, with the primary objective of seeing whether the practice's "image" meets it own expectations.

"When you're evaluating staff and physicians with surveys, you get some information, but it's also nice to have someone who is savvy about what's appropriate in the office," says Jay Grossman, MD, president of the practice.

Grossman recently hired professional mystery patient Meryl Luallin, a partner in the San Diego consulting firm Sullivan/Luallin, to evaluate such factors as how well new patients were informed about office practices, how quickly the patient was moved from waiting room to exam room, and the physicians' demeanor and general bedside manner.

"We want everyone to treat our patients like they are their mother or grandmother -basically, the way we all want to be treated," Grossman says, adding that the benefits include the objectivity of the process and the opportunities for staff improvement it uncovers. "When [staff] receive feedback from somebody who has no vested interest other than to try to be impartial, then it's not the doctor saying it - it's from a patient's standpoint," he says. "It's supposed to be constructive, not destructive."

For example, Dermatology Specialists has used the process to help a physician figure out why he constantly ran behind - and to help the tardy doctor devise his own method for staying on track.

Go to the source

Practices use mystery patients to ferret out the source of a problem. Mary Maloney, vice president and chief educator at the Pittsburgh, Pa., marketing firm Adam Filippo & Associates, recalls a situation in which a Pennsylvania practice with serious service issues used a mystery patient to tie problems to their source: a dissatisfied receptionist.

"She was the practice's 'golden gatekeeper' - a position she'd held for 20-some years - and she was just miserable on the phone," Maloney says. It turned out that the woman was a competent, caring individual who still wanted to work at the practice - but she was very unhappy in what had become an unchallenging job for her.

Maloney's third-party perspective and resulting documentation gave another practice the armor it needed to fire a receptionist - the best friend of one of the physicians' wives - who was rude to patients, presumably because she thought she was above reproach.

"Everyone in the office knew it was a challenge, but no one wanted to touch the situation with a 10-foot pole," Maloney says. Despite the fact that the receptionist was advised in advance that the practice was being "monitored," Adam Filippo's mystery patient callers found that she behaved in much the same way other staffers had reported, and the woman was eventually terminated with cause. "We probably did her a favor, but we were also able to take a monkey off the practice's back in a diplomatic way that made an ugly situation a little smoother," Maloney recalls.

Most practices hire mystery patients to assess the entire experience, but University Physicians Inc. (UPI), a 400-physician academic practice affiliated with the University of Maryland School of Medicine, used mystery patients to evaluate how callers were treated when they phoned to make appointments, and whether that experience met the practice's established standards.

"What we learned was that it's not just people issues that caused receptionists to meet standards in one call and fall far below those standards in another," says Chris Hipple, UPI's director of training and performance management. Ultimately, the data UPI gathered was incorporated into future training programs.

Luallin notes that mystery patients often uncover unexpected faux pas, such as the physician who apparently didn't realize the negative message she was giving when she shook patients' hands while wearing rubber gloves. Another physician discovered that she spent an unacceptable amount of time with her back to the patient. With Luallin's coaching, they were able to change their behavior.

"What surprises doctors is that they sometimes inadvertently come across as uncaring and rushed," Luallin says, because of behavior that might not be documented in a patient satisfaction survey.

To tell or not to tell?

When it comes to whether mystery patients' planned "visits" should be disclosed beforehand, there are two schools of thought. Luallin and Eliscu cast their votes for telling staff beforehand, and then having the mystery patient show up weeks or months later, when, presumably, people are no longer actively "looking out" for an undercover patient.

Suzanne Boswell, head of Healthcare Impression Management Services in Raleigh, N.C., and author of The Mystery Patient's Guide to Gaining and Retaining Patients, thinks it's better if staff don't know beforehand, even though that makes her job - delivering the results and offering constructive recommendations for change - more difficult. "There are mixed reactions when [staff and physicians] find out they've been visited, so I'm walking a delicate path," Boswell says.

If something untoward happened, or a situation occurred that would make someone feel picked on, Boswell discusses it privately with the person. "I have to make sure the team is intact when I leave," she says.

Regardless of which way you go, realize that hiring mystery patients is an expensive proposition, costing roughly $500 to a few thousand dollars, depending on the number of "visits" and the follow-up reporting and training provided.

If it's not handled properly, the process could negatively affect employee or physician relations. That's why it's critically important to approach the process carefully. Besides ensuring the mystery-patient firm is reputable, has relevant experience (insist on references and check them out), and is prepared to customize the job, the practice should determine in advance exactly what it wants to assess and how it will proceed if serious problems are uncovered.

Bonnie Darves can be reached via editor@physicianspractice.com. 

This article originally appeared in the September/October 2001 issue of Physicians Practice.