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Surviving Managed Care^© Newsletter

Volume 3, Number 2 Summer, 2001

Vision and Eyecare Business Information For The Millennium

Objectives:

To understand the importance of using patient satisfaction surveys to measure and improve practice performance; to review the proper construction and use of these surveys; to learn how to benefit from OSHA's free site inspection service.

  Effective Patient Satisfaction Surveys

Why It's So Important To Know What Your Patients Really Think

It's a sad fact of life that physicians often are unaware when a patient leaves the office dissatisfied with the service he or she has received. Perhaps the patient will keep the upset to herself, never to return to the practice. And the practice never knows why that patient and, perhaps, her entire family suddenly request their medical records be transferred to another practitioner.

Even worse, a patient may tell others a story reflecting his lay-perception of events, usually leaving out critical facts unknown to or unappreciated by him. That bad word of mouth can have a domino effect, rippling through the practice's patient base and, perhaps, even reaching to the management of an HMO or other party.

If a patient files a formal complaint with a healthplan, medical society, or state agency then at least the physician will hear about it through formal channels and have a chance to respond using that entity's grievance protocols. The physician will be told who filed the complaint. And there is a measure of confidentiality in the process. It may not be pleasant, but at least it's structured.

Today, however, there is a new and potentially ominous threat to physician reputations. Web sites are popping up on the Internet where disgruntled patients can vent their anger at physicians in public and, essentially, unconstrained. Though you might not know the patient is unhappy, the rest of the world could know. And that should certainly concern every physician and practice administrator.

While none of these sites is yet a repository of many physician complaints, it's clear that they have the potential to become problematic, and they should not be dismissed or ignored. You should know that these sites do not verify the validity of any complaints - they only provide a forum for posting them. In many cases these sites allow anonymous postings and confirm only that the complaining party used a valid e-mail address.

Perhaps even more distressing, unless the complaining party provides complete physician contact information, some of the sites make no effort to contact the physician against whom the complaint has been lodged. This means the physician probably does not know a complaint has been posted on a public forum. He or she also has no opportunity to reply to the patient's public denouncement (though, obviously, if one knew about the complaint any response should be handled in confidentiality, directly with the patient, and never addressed in a public forum such as an Internet e-mail complaint board).

Even absent this newest means for disgruntled patients to vent their anger, It's clear that physicians need to do a better job understanding why patients feel good or bad about their care. And practices need to create handy mechanisms that allow patients to provide constructive criticism minimizing anger and frustration, and so that patients can leave the physician's office satisfied with their care and confident in that doctor.

It's Much More Than Simply Asking The Obvious Questions

At one time or another nearly every ophthalmology practice has surveyed its patients in an effort to answer that all-important and multi-dimensional question: How are we doing? For some the results proved enlightening. Perhaps the practice was able to effect meaningful change.

For others the results may have been unclear or hard to interpret. Or, perhaps, if the return rates were very low, there were no meaningful results on which change could be made and then measured.

In my 22 years in managed care and practice management I've read numerous patient surveys, and I've found nearly all of them had serious design flaws. Many asked only the most obvious questions - the answers to which were probably predictable and not particularly enlightening. Others asked a few good questions but buried them in the middle of too lengthy documents. In the end these efforts yielded precious little information useful for planing and effecting meaningful change.

In this issue of Surviving Managed Care^© I'll discuss some of the common problems with patient satisfaction surveys. And I'll give you some tips on how to design better surveys and how to extract more useful information from them.

Asking The Wrong Questions, Or Asking An Ineffective Question

It's essential that you ask the right questions, and that you word them to elicit useful responses. A question that gets you little or no useful information is space wasted. Here's an example from an actual survey:

Are our fees reasonable compared to other eye doctors? ____ yes? ____ no?

Think about the patient who's replying, and what the response means. If it's a managed care patient that person may be in your office because you were chosen by a Primary Care Physician, or referred to by another ophthalmologist. Perhaps the patient had no input on the choice. The patient's only responsibility may be a $10 co-pay. On what basis does that patient make any judgement that your fees are or are not reasonable compared to other eye doctors?

Or, assume the patient is paying your full fee. But her previous eye exam was from an optometrist three years ago. Let's say the OD charged $55 then. (Obviously you're not aware of this fact.) Your charge now is $90.

It's an apples and oranges comparison, but the patient may not realize it. If she answers "no" to the question based on paying so much less the last time does that response give you valid information on which to measure her satisfaction with your practice today? I suggest it does not.

If you're concerned about measuring patient sensitivity to fees perhaps a better way to inquire and get an apples-to-apples comparison might be along these lines:

Not counting HMO and PPO copayments or deductibles, were your out-of-pocket expenses reasonable compared to those of any other ophthalmologist you've seen in the past two years for similar services? ____ yes? ____ no?

Please explain ___________________________________________________

Do you see the difference between the original, nebulous question and the tighter alternative? This is how you must think in writing every survey question. Each must elicit a measurable response to a narrowly focused question.

Appreciating this important fact, what then goes into making a good patient satisfaction survey? I think there are three components that will make or break your efforts. Let's discuss each of them.

1)  Asking The Right Questions

It's so easy for the survey to fall flat if you don't know what to ask. Consider that there are two sets of "right" questions - those concerning issues you know matter to the patients, and those you may not realize are important to them.

The first is obvious - questions everyone already knows they must ask. Thus, you might create carefully worded inquiries to probe into and measure performance in these traditional areas: (This is only a partial list.)

• Appointment: Easy to make? Available at a convenient time?
• Phone: Courteous staff? Prompt response or left "on-hold"?
• Reception: Greeted in a prompt and courteous manner?
• Neat and professional appearance: Of personnel? Of facility?
• Waiting room: Length of time before called?
• Doctor: Answered all questions? Seemed interested?
• Staff: Answered all questions?
• Check out procedures: Quick? Payments handled smoothly? Next appointment easy to schedule?

The second, and often unasked set of questions can be even more important. These less obvious questions are often the ones that can reveal hidden issues you did not know existed, and which you'd never know about unless patients were give the chance to respond. The key here is to think outside the traditional box, to get inside your patients' heads. You're looking to find the sources of small irritations that can result in very upset patients, or small pleasures that can make for very happy patients.

So, for example, you might craft some questions to probe into these areas:

• Directions: Staff provided concise driving or public transportation information?
• Signage: Easy to see from outside?
• Parking: Adequate? Close to entrance?

Consider the importance of staff being able to provide concise driving directions or information on using public transportation. Have you ever called a business (for example, a bookstore) and asked for directions only to be told "Sorry, I don't live in the area. I don't know how to get here from where you are."

It's happened to me, and when it does I take my business elsewhere. But the original merchant will never know that his staff's failure to address this simplest request resulted in lost business. Your patients may opt to do the same, so you need to know to probe into these hidden areas.

The key here is to ask the patients what's important to them, not what's important to you. Let me relate a story demonstrating how crucial this is to eliciting meaningful responses.

A pediatrics clinic conducted a patient satisfaction survey. Now obviously the patients (infants and young children) did not complete the survey; the parents did. The survey designers asked all the usual questions, but they were savvy enough to leave space at the bottom and asked:

Please tell us about things we're doing right or wrong that we did not think to ask about.

The results were fascinating and so very revealing. The respondents' top three positives (i.e., what you're doing right and why we like coming to this office) were:

• Parking - as long as there was plenty of parking and the parents did not have to circle the lot endlessly with a crying child, the parents were happy.
• Teddy Bears - the waiting room was full of soft toys for the kids. As long as the kids were occupied the parents did not mind waiting for them to be seen.
• Cookie Cart - there was a cookie cart and fresh baked cookies for the kids. It kept them smiling and quiet. The parents loved that and did not mind waiting.

These were all items that the practice had not even considered when writing the survey. No one had realized that for the parents of this practice having their children seen at exactly the scheduled appointment time was far less important than an environment minimizing opportunities for the children to cry. No one in the practice realized the importance of little touches like the Teddy Bears and cookies over more traditional survey inquiries. (e.g., "Was our selection of magazines adequate"?)

So it's essential that your survey includes a section where you give the patient plenty of opportunity to "vent" or to praise on issues you did not think to ask about.

2)  Acting On The Results

The second key component to an effective patient satisfaction survey is to take appropriate and timely action based on the survey results. Now, certainly this does not mean you implement each and every change suggested by a patient. To do so would have your staff whip-sawing back and forth in unending confusion. You also don't get crazy with your appointment schedule simply because a small number of patients thinks seven days is too long a wait for a non-emergency appointment.

But it does mean that the physician needs to meet with the administrator and staff to discuss the survey results and to determine what changes, if any, can and should be effected (and, of course, how to go about that). Certain survey results or suggestions, especially if they're made by different patients, are slam-dunk candidates for immediate action. For example you must have adequate signage so patients can find your office. In that case a staff person would be put in charge of assessing the current signage and developing an action plan for necessary upgrades.

Other results such as "You should add an additional entrance to the optical shop" may go lower on the priority list due to costs, or may not be considered at all due to logistics (e.g., if there is a structural beam in the wall making it impossible to add the suggested entrance).

Good survey results and enlightening information do you no good if the practice takes no corrective action. But that action needs to be responsive rather than reactive. There's a very important difference between the two.

3)  Measuring The Results Over Time

OK, so you've surveyed and collected a lot of good information. You met with the staff and made some changes based on patient input. It's been awhile and you decide it's now time for another survey.

At this point many practices make a crucial mistake. They send out a new survey but change it significantly - asking a fundamentally different set of questions. And that effectively leaves them back at square one since these new questions don't measure how well or if the practice has improved from the previous survey, or if the changes have had any effect on patient satisfaction.

And so the third key component to an effective patient satisfaction survey is measuring performance change over time - carefully re-examining the key issues from the prior survey. Of course as you identify new issues you'll add some of them to subsequent surveys, but the core questions need to remain intact in order to develop a "measuring stick" for assessing how you've done.

So, how do you create that "measuring stick"? It's created automatically by the responses, but the quality of the measuring stick is determined by the manner in which you ask for patient responses.

In my opinion asking "yes/no" questions returns the least useful information since it's black or white - there's no room for the patient to qualify a response. Numerical responses (e.g., 1-5) or descriptive responses (e.g., excellent, very good, good, fair, poor) are better than yes/no. But they're still problematic since, for example, a "poor" response doesn't tell you why the patient felt that way.

The best structure for building an effective measuring stick combines graded responses and descriptive commentary. This means that the survey must provide space for comments and encourage each patient to use the survey as a means to "talk" to the practice about his or her experience. Thus, if a patient indicates that the staff responsiveness upon checking-in was only "fair," you need to understand the specifics of that rating in order to look into the matter (especially if staff responsiveness comes up often as a patient-perceived problem).

At a minimum this means providing space on the form and asking the patient to explain any unfavorable response, or certainly any unfavorable response below a certain rating (e.g., 2 or below on a 1-5 scale). Preferably it means providing space and encouraging comments for every response, good or bad. Patients will respond; they want to be helpful even if their experience was not all that positive.

Make It Easy For Your Patients (And Your Staff)

Remember, too, these points when designing and implementing a patient satisfaction survey:

• Keep it short - preferably one page (two-sided) to encourage replies,
• Keep it succinct - Write concise questions to solicit revealing answers,
• Provide a pre-addressed, postage paid envelope or a fax number for replies.

Finally, remember to leave adequate space at the bottom and ask: Is there anything else you'd like to tell us that we didn't think to ask?

(Note: for helpful suggestions on effective referring provider satisfaction surveys see Surviving Managed Care^© (Spring 2000): Increasing Practice Profitability: Growing An Already Viable Referral Base vs Pursuing New (Possibly Marginal) Contracts.

  OSHA's Free (And Painless) Consultation Service

Over the years many if not most ophthalmology practices have been through a facility expansion or come face to face with some other issue subject to OSHA regulations and oversight. Perhaps yours involved the disposal of hazardous materials byproducts created in the production of spectacle lenses at your new optical lab. Perhaps you added a laser facility. Or perhaps you're not even aware that you may have OSHA issues.

OSHA is always a concern, and that concern should extend to your managed care business. If your facility fails an OSHA inspection it's quite conceivable that a healthplan could terminate your provider agreement "with cause" (citing, for example, that the unsafe conditions could put their Members at unacceptable risk). Obviously losing a managed care contract over an OSHA violation is something you can and must avoid.

OSHA is one of those powerful government agencies that everyone seems to fear and is desperate to avoid. In the back of many physician and administrator's minds are common worries: Are we going to have problems with OSHA? And how do we avoid the turmoil that always seems to accompany an unfavorable OSHA inspection?

Well, there's encouraging news for those facing or potentially facing OSHA issues. You can be pro-active.

OSHA provides a free consulting service for smaller businesses. You can learn about possible hazards in your workplace and find out how to improve and manage your safety systems. OSHA's safety and health consulting program is confidential and not part of its inspection program. Your name, the facility's name, information you provide to the consultant, and any unsafe or unhealthful working conditions are not routinely reported to OSHA's inspection division. However, in exchange for the free consultation you agree to act on the consultant's recommendations and to correct any serious health or safety problems within a reasonable time.

How The Program Works

You initiate the free consultation by contacting OSHA. A complete list of all OSHA offices offering free consults is at http://www.osha.gov/oshdir/consult.html. A consultant will discuss your needs and then schedule an appointment. You have the option to schedule a review of all your safety and health matters or you can request to have the consultation limited to a specific concern.

When the consultant arrives at your office here's what will happen:

• First the consultant will conduct an "opening conference" during which you'll learn about his or her duties and your obligations as a participant in the program.
• Next the two of you will do a facility walk-through. The consultant will also talk with your employees and gather information. You'll learn about OSHA standards applicable to your inquiry and to other matters that may not fall under OSHA but which the consultant may observe.
• After the walk-through the consultant will review his or her findings in a "closing conference." You'll get feedback on what's wrong and what's right. You can then discuss any problems, possible solutions, and time frames for making necessary corrections to matters deemed serious hazards.

Following the on-site meeting you'll receive a written report detailing the consultant's findings, necessary corrections, and the time frames agreed upon during the "closing conference." The consultant will monitor your progress on any required corrections so as to achieve the goal of the program - the protection of all workers and a safe work environment.

Note: If you fail to complete the necessary corrections according to the plan and in the time frame you agreed to, then the matter can be referred to OSHA's enforcement office for action. You'll want to avoid this and OSHA indicates such referral is rarely ever necessary.

Note also: If the consultant finds an "imminent danger" during your meeting you will be required to take immediate action to protect your employees. The consultant will help you with a plan to effect the immediate correction.

Finally, the consultant will not:

• Issue citations,
• Report possible violations to OSHA enforcement,
• Guarantee that your practice will pass a full-blown OSHA inspection.

These materials are intended to provide useful information about the subject matter covered. The author believes that the information is as authoritative and accurate as is reasonably possible and that the sources of information used in preparation of the materials are reliable, but no assurance or warranty of completeness or accuracy is intended or given, and all warranties of any type are disclaimed.

The materials are not intended as legal advice, nor is the author engaged in rendering legal services. The materials are not intended as a replacement for individual legal or professional advice. Information contained herein is presented only for illustrative purposes, and it should not be used to establish any fees or fee schedules, nor is it intended and it should not be construed as encouraging any user of the materials to take any actions that would violate any state or federal antitrust laws, tax laws, or Medicare or Medicaid laws.

Copyright © 1998-2000, Gil Weber, MBA. No part of this newsletter may be reproduced or distributed in any form whatsoever without the author's prior written authorization.

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