Progressive Focus©

Progressive Focus© Newsletter


Volume 4, Number 1 Spring, 2003
Helping You Manage the Expectations of Managed Vision Care

In This Issue:

Patient Satisfaction Surveys

Understanding How Patients Feel About Your Practice, And Why...
Then Initiating And Measuring Change


Truth is one forever absolute, but opinion is truth filtered through the moods, the blood, and the disposition of the spectator.

Wendell Phillips

You work long, hard hours caring for your managed care patients' visual needs. And at the same time you take care to perform to the terms of your third party provider agreements.

It's unfortunate that optometrists sometimes are unaware when a patient leaves the office dissatisfied with the service she has received. Perhaps the patient will keep the upset to herself, never returning to the practice. Perhaps you'll never know why that patient and her entire family requested transfer of their records to another OD.

Even worse, patients may tell others stories reflecting lay-perceptions of events, usually leaving out critical facts unknown to or unappreciated by them. That bad word of mouth can have a domino effect. It can reach the management of a local insurance plan or a corporate human resources department. The bad word can even travel across the country to the offices of a national vision plan.

As a result of such complaints practitioners sometimes receive a letter from the payer announcing a quality assurance or provider facility audit. If a patient does file a formal complaint with a health plan or a state agency at least you may hear about it and have some means to respond using that entity's grievance protocols. And, in most cases, there is a measure of confidentiality.

A New and Ominous Threat

But today there is a new and potentially ominous threat to your reputation. There are several websites where disgruntled patients can vent their anger at you, in public and, essentially, unconstrained.

These are just three – there are many others. While none of the sites is yet a repository of many eyecare provider complaints, it's clear they have the potential to create problems. You should know that some sites do not verify the validity of complaints. They only provide a forum for posting them. In many cases the sites allow anonymous postings and confirm only that the complaining party used a valid e-mail address.

Internet Complaint Sites
Rip-off Report

Some of the sites make no effort to contact the person or business against whom the complaint has been lodged. Thus, you may never know that a complaint naming you has been posted on a public forum.

It's worth a look at some of these complaint sites to see just how irate patients can get. Their "rants" make it clear why every OD needs to a better job understanding whether patients feel good or bad about the practice.

This means creating handy mechanisms that allow patients to provide both praise and constructive criticism, and so that they leave your office satisfied with their care and feeling confident in their doctor.

And there's another important reason why it's important to know what your patients are thinking in order to minimize the occurrence of patient complaints. Even if your patient does not initiate a complaint to a payer, those entities conduct their own satisfaction surveys. Negative patient feedback has resulted in optometrists being removed from provider panels.

So let's look a little deeper into the hows and whys of effective patient satisfaction surveying.


Quality: Meeting or exceeding customer expectations at a cost that represents value to them. It's a personal thing, and everyone defines it in his or her own way.

H. James Harrington
The Improvement Process – How America's Leading Companies Improve Quality

The Fundamental Question

At one time or another nearly every practice has surveyed its patients in an effort to answer that all-important and multi-dimensional question: How are we doing? But effective surveying involves a lot more than simply asking that question.

Patient feedback from surveys has often proven marginally useful at best. For many practices the results were unclear or hard to interpret. And, if the return rates were low, there were no meaningful results on which change could be made and then measured.

In fact, most surveys have serious design flaws. They ask the wrong questions, or they ask ineffective ones. And, typically, they'll ask only the most obvious questions -- predictable and not very enlightening.

Other surveys ask a few good questions but bury them in the middle of far too many unfocused questions. It's essential to ask the right questions and to word them so that they'll elicit useful responses. A question that gets you no useful information is space wasted.

Here's an example of a common, poorly written question from an actual survey:

Are our fees reasonable? ___ Yes ____ No

Think about the patient and factors that might influence his answer. If he's from an HMO he may be in your office simply because your name was on a list. Let's say his only responsibility today is a $15 vision plan copay. On what comparative basis does that patient make a judgment that your fees are or are not reasonable? Compared to whom? To other ODs? To ophthalmologists? To independent opticians?

Or assume that your patient is a private pay, but her previous exam was under a vision plan three years ago from an OD in a retail chain setting. She paid $20 back then and your fee today is $95. It's an apples to oranges comparison, but the patient doesn't appreciate that. If she answers "no" (your fees are not reasonable) how valid can that answer really be?

So instead you might consider a question crafted more along these lines.

If you had any out-of-pocket fees (not covered by insurance), were they reasonable compared to those of any other optometrist you've seen in the past two years for similar services? ____ Yes ____ No

If no, please explain ____________________________________________________

Now, I'm not suggesting that this is the perfect question for every practice, but do you see the difference in how its structure narrows the focus of the inquiry compared to the original example? Each question in an effective survey must elicit a measurable response to a narrowly focused issue. That, then, gives you a way to compare apples to apples.

What Are The "Right" Questions?

The first key component to any survey is to ask the right questions.

Obviously these will differ practice to practice. Dr. "X's" patients in car-dependent Los Angeles may have quite different concerns than Dr. "Y's" patients who rely on public transportation in New York City. And Dr. "A's" largely geriatric and Hispanic practice in Miami's "Little Havana" may have quite different concerns than Dr. "B's" younger, "in-crowd" patients who live and work around Miami's South Beach. This means that there is no such thing as the ideal survey that can be copied from a book or pulled off the Internet and then cookie-cuttered by any practice.

In all cases there are always two sets of "right" questions -- those on issues you know matter to the patients and those you may not realize are important to them.

The first set is obvious. Thus you might include carefully worded inquiries to probe into and measure performance in one or more of these traditional areas (partial list only):

  • Ease of making appointment?
  • Staff courtesy on the phone? At check-in?
  • Doctor and staff answered all your questions?
  • Check-out quick and easy? etc...

I suggest that you should not need to waste precious survey space asking questions such as: Is our magazine selection adequate?

Something so basic, so expected as adequate and current waiting room reading materials should never need to come up as a survey issue or patient response. Shame on any practice whose patients feel it necessary to reply with a sarcastic "dig" (Gee, I just found out from one of the magazines in your waiting room that Jay Leno has taken over as host on the Tonight Show.).

The second and frequently unasked set of questions can be even more important. These are inquiries that often reveal issues whose significance you'd never fully appreciate unless patients were given a chance to comment

Here you're thinking outside the traditional box. So you might craft some carefully worded questions to probe these areas (again, not a complete list):

  • If requested, did staff provide concise directions to the office?
  • Was there adequate signage? Easy to see from street?
  • Were various eyeglass options such as progressive (no-line bifocal) or high-index lenses adequately explained to you?

Whatever you ask, it's essential that your survey include space for the patients to vent or praise on each question.

Making Appropriate Changes

The second key component to an effective survey is to take appropriate and timely action based on the survey results.

Certainly you're not going to implement every change suggested by patients. But it's essential that doctor(s) and staff discuss the survey results to determine what changes, if any, can and should be made. And, of course, you discuss just how you'll make that happen

Certain suggestions are slam-dunks. For example, you must have adequate, outside signage if patients are to find your practice. And if they tell you that you don't then this is something requiring immediate attention. Assign a staff member to that project tomorrow!

Other frequently submitted suggestions may prove to be impractical or impossible. For example, many patients may request a second entrance into your optical dispensary, but if there is a structural support in the wall that precludes such construction then the suggestion, no matter how good, is moot.

In all cases it's worthwhile to let your patients know when you've made changes based on their input. For example, if you extend office hours based on patient requests, or if you start a payment finance program, say so. You might post a sign in the lobby, or announce changes in your patient newsletter.

However you do it, this gives your patients a sense of empowerment. It's a great loyalty builder.

So let's assume that you've surveyed and collected some good information. Doctor(s) and staff meet and make some changes based on patient input. It's been awhile and you decide it's time for another survey. At this point many practices make a critical mistake.

Presuming they've resolved issues raised in the previous survey, and seeking feedback on additional areas of interest, this new one is changed significantly. It asks fundamentally different questions. But that effectively leaves the practice back at square one since these new questions don't measure how well or if the practice has improved from the previous survey. And they don't measure if the changes have had any effect on patient satisfaction.

Measuring Performance And The Impact Of Change

And so the third key component to an effective survey is to measure progress over time. Essentially you must determine if your efforts since the prior survey have made a positive difference.

Of course you'll identify new issues and add some of them to the new survey, but the core questions remain intact in order to develop a "measuring stick" for assessing how you've progressed. But, how do you create this analytical measuring stick? Well that's determined by the manner in which you ask the questions.

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 format combines graded responses and descriptive commentary. This means 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 experiences.

Thus, if the patient indicates that staff responsiveness upon check-in was "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 problem). At a minimum this means providing space on the survey 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 scale of 1-5). 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. Remember, too, these points when designing and implementing a patient satisfaction survey:

1)   Keep it short to encourage replies -- preferably one page (two sided).

2)   Keep it succinct -- write concise questions to solicit revealing answers.

3)   Provide a self-addressed, postage-paid envelope or a fax number for the replies.

And, finally, remember to leave space at the end for the most important question of all.

Is there anything else you'd like to tell us that we did not think to ask?

You might discover that your patients raise some great issues that never showed up on your radar screen.

Guest Commentary:
Richard C. Edlow, OD

Premium Products = Patient Satisfaction = Financial Growth

Fascinating anomalies exist within the eye care industry. One seems to defy the most basic law of economics, the law of supply and demand. Another equates higher patient satisfaction with the consumer paying more for eyewear. And yet another makes it appear that because eye care providers fear charging more, they often may fail to recommend the highest quality vision products for their patients. Please allow me to explain.

Studies sponsored by the American Optometric Association and the American Academy of Ophthalmology have concluded that there may be an oversupply of eye care providers relative to current levels of demand for services. Regardless of these analyses, studies amongst eye care providers continue to reveal that income levels are rising faster than the eye care inflation rate and the overall consumer price index.

The reasons for this are varied, but I believe one of the most influential factors is the appropriate recommendation and dispensing of premium frame and lens products. The advantages for the patient include greater comfort (e.g., reduced weight from both frame and lens materials), improved cosmesis, and enhanced visual performance.

My observations lead me to believe that patients who spend their money on the finest of frames, thinnest and lightest lenses, newest generation anti-reflective treatments, and best progressives are highly satisfied and motivated patients. They routinely spend more and, significantly, they refer more often.

When was the last time a patient walked out of an eye care practice excited about her new, least expensive frame with thick, non-treated -5.00 CR-39 lenses? On the other hand, everyday patients walk out of our offices excited about the lightest glasses they ever had -- eyewear that looks awesome and now allows them to comfortably view their computer screens without any glare. And, guess what - those patients spent 3-5 times more on their eyewear, and they're thrilled about the whole experience.

Another anomaly that I often observe is the eye care provider overly concerned about charging a patient more for new eyewear. I am all for making sure the patient doesn't spend unnecessary dollars, but I am also all for making sure that my recommendations provide my patients with the best possible visual performance. What's the point of prescribing multi-focal lenses to enhance visual performance at the computer if the patient ends up with the limited focal lengths of a flat-top? What's the point of dispensing a new Rx for a patient having difficulty with night vision if those lenses don't include an AR treatment?

The bottom line -- you can maximize both patient satisfaction and practice finances by routinely prescribing today's premium materials.

Dr. Edlow is Chair of the AOA's Information & Data Committee, the source for surveys and dissemination of data relevant to the eye care industry. He frequently writes and lectures on optometric business and marketing issues.

Education is what you get when you read the fine print.

Experience is what you get when you don't.

Copyright © 2003-2007, Gil Weber, MBA. No part of this newsletter may be reproduced or distributed in any form whatsoever without the author’s prior written authorization.

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.

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