These days, physicians are subject to increased scrutiny — our charts are being reviewed, patient care data analyzed, and compliance to a myriad of regulations checked. And now that state and federal government agencies are starting to post the results of inpatient hospital patient satisfaction surveys, it is only a matter of time until ambulatory practices will be added. So, should there be any surprise that the mere mention of a patient satisfaction survey hits a nerve? It is one more breach in our already fragile autonomy, just another instrument exploited by regulators to influence our professional behavior.
But with market alliances changing at an alarming pace, now is not the time to take our patient or referring base for granted. Any tool that helps to promote our practices and identify ways to improve them can be an asset. Even if we think patients are happy with our care, surveys can make it easier for us to focus on how we can do better.
Jan Mashman, MD, whose Danbury, CT, practice was formed in 1971, has learned to take customer satisfaction seriously. “It's important to be sure you are viewed as ethical, principled, and as treating people with dignity and respect,” Dr. Mashman said. “It takes about twenty good reviews to erase one bad customer experience.”
His nine-physician neurology group, Associated Neurologists, PC, has a committee dedicated to patient and physician satisfaction. The neurologists wanted to be sure that the instruments were reliable, had already been tested and validated, and that the statistics were interpreted professionally. So they hired a firm to help develop two questionnaires, one for patients and another for referring physicians.
The practice evaluates the responses, follows through with actions based on the feedback, and informs respondents about any changes. Said Joyce Peters, director of business development and operations at Associated Neurologists, PC: “If you ask the types of questions that correlate strongly with overall satisfaction and likelihood to refer your practice to others, you'll get data that are useful in steering your improvement efforts and investments.”
Just asking for input sends the message that you are committed to improving your quality and service, Peters pointed out. It's a message that's good for business too.
SURVEY RESULTS ONLINE
Bethlehem, PA, neurologist Jeffrey D. Gould, MD, who works in a practice with two physician assistants, posts survey results online. He includes a patient satisfaction survey along with a separate nerve conduction and EMG survey on his NeurologyChannel.com created Web site, which costs $75 per month to maintain and includes customization features such as electronic survey tools.
Office staff members distribute the survey to patients as they are leaving, giving them time to complete and return them to the checkout clerk, ensuring a nearly 100 percent response.
Both patient satisfaction and referring physician satisfaction surveys can also shed light on how the office is perceived by patients or referring doctors' secretaries — including experience with setting up appointments, getting referrals and records, said Meryl Lualllin, a partner with the consulting firm Sullivan Luallin, Inc. “You don't know what patients are saying about your practice when they leave your office unless you ask,” she said. “Patients return from a specialist and go to their primary care doctors and tell them if they've had a bad experience.”
Even if we don't create them ourselves, patient satisfaction surveys are taking place — by consumers on the Internet, by insurers, and by hospitals. In many large groups and academic centers, patient satisfaction surveys are not a choice, but a responsibility. In fact, many organizations have begun to include the results in physicians' compensation formulas.
Neurologist David A. Nye, MD, has been practicing 26 years at a large multispecialty clinic in Wisconsin that will soon use patient satisfaction surveys to calculate his salary. Press-Ganey, a corporation that specializes in health care quality research and reporting, mails out questionnaires to a sample of patients and produces reports by physician and department. In addition to reporting satisfaction percentages — which compare the physicians to each other physician clients from other areas — it lists areas with the greatest need for improvement, such as waiting time in exam room or convenience of parking.
“These show little reproducibility from report to report however, leading me to wonder just how accurate they are,” Dr. Nye said. He suspects that when patients have a bad office visit — perhaps because they are given news they don't want to hear, or their request for narcotics or disability has been denied — they give low marks on everything indiscriminately.
Indeed there are many intangibles that factor into scores. In the Department of Defense system, patient satisfaction surveys, as a subset of customer satisfaction surveys, are ubiquitous and de rigeur, noted Col. Jonathan Newmark, MD, a neurologist who has worked at several Army hospitals.
He was initially puzzled why one of the larger, more bureaucratic facilities — where it was harder to get things done — always received the top patient ratings. He ultimately discovered that a disproportionately high percentage of patients were retirees — a group that was grateful to receive free care. Moreover, many patients had been there for years having developed decades-long relationships with their doctors and staff, loyalty that is reflected in survey results.
“This process is uncomfortable but inevitable, with positives and negatives for both physicians and patients,” said Dr. Nye, adding that the physicians are consequently directed to engage in quality improvement projects to tackle the top areas of patient dissatisfaction. He and his colleagues took part in mandatory classes in customer satisfaction when the program was rolled out two years ago.
“If we work harder on being nice to patients,” he explained, “patients will generally be nicer right back, more cooperative with their treatment, and less likely to sue. Business people have been doing this for centuries,” he said.
Dr. Nye's greatest concern, shared by many, is that the scrutiny, especially if scores affect salary, may lead to “cherry picking and lemon dropping” — physicians changing their practices in subtle ways to try to hold on to happy patients and drop ones who will not rate them well.
Physicians may stop accepting chronic pain referrals, for example, he said; instead, referring patients who request pain medication for chornic migraine and work-related low back pain to other physicians.” Furthermore, if there is some division of labor within the department, one provider (the chronic pain specialist, for instance) may be doomed to lower scores than another (perhaps the sleep disorders specialist), but the scoring system and perhaps the medical director may not take this into account.
But regardless of flaws, surveys make great marketing tools. Said Peters: “What is most important to our patients and referring physicians is that we are actively asking, listening, and responding to them.”