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Patient satisfaction surveys: how to do them right

You need to ask the right questions, get enough responses—and then put the information to good use

From the April 2000 ACP-ASIM Observer, copyright © 2000 by the American College of Physicians-American Society of Internal Medicine.

By Bryan Walpert

Plenty of physicians talk about satisfying patients. Then there's Cardiology of Tulsa.

The 19-cardiologist practice in Oklahoma spends upwards of $30,000 a year on patient satisfaction. It employs a registered nurse with an MBA to run a quality improvement program. And it conducts three surveys each year, two created in-house and one by a consultant.

Perhaps most importantly, the practice pays close attention to its survey results. When patients said access was a problem, for example, physicians responded by increasing the number of patients they scheduled per half-day, increasing the practice's patient volume.

"We want to make sure we're giving the proper care, and we want our patients to be happy with that care," said Edward J. Morris, MD, a cardiologist and physician advisor to the group's quality improvement committee. "We want to know that we're doing the right thing."

The practice has put its money where its mouth is. In 1997, it began linking the pay of its physicians to survey results. Today, 12.5% of each physician's pay depends on the happiness of his patients.

Nationwide, satisfaction surveys have long been popular among health plans and employers. Increasingly, experts say, physicians are also conducting surveys, and for good reason.

"Every single practice in this country, no matter how big, has competitors who want their patients," said Kevin W. Sullivan, president of Sullivan/Luallin Inc., a San Diego-based patient satisfaction consulting firm that works with physicians. "If you don't know what your strengths and weaknesses are, you can't compete."

But experts point out that measuring patient satisfaction isn't as easy as slapping a few questions on a card. They say the process needs to be carefully mapped out, from the way you ask questions to the way you respond to results.

"More and more practices and clinics are making the effort and spending the resources to do it. The thing is, are they doing it in a way they will be able to use the results?" said Phyllis Fleming, PhD, president of Loyalty@Work, a consulting firm in Minnetonka, Minn., that focuses on customer loyalty. "Sometimes that's not the case."

Here are tips from consultants that can help you plan and conduct a patient satisfaction survey to help you avoid trouble:

  • Ask the right questions. Choose questions carefully, or your survey won't give you the information you really need. "The last thing you want to do is sit around with the staff in the practice, hammer out a few questions, hand it out to a couple hundred patients and base major decisions on the responses you get back," said Jerry Seibert, president of Parkside Associates Inc., a health care survey research firm in Park Ridge, Ill.

Mr. Sullivan said surveys typically cover the following areas: access (ease of getting through on the phone, ease of getting an appointment, waiting times); communication between patient and office (quality of health information materials, ability to get a call returned, getting tests results back quickly); staff (courtesy of the receptionist, caring of nurses and medical assistants, helpfulness of people in the business office); and the interaction with the doctors (whether the doctor listens, thoroughness of explanations and instructions, whether the doctors take time to answer questions, how much time the doctors spend with the patient).

It's easy for practices to devote too many questions to waiting rooms and waiting times, Mr. Seibert said. "Those are not unimportant, but they pale in significance to the interaction between the physician and the patient," he said. "What we find is that the interaction between the patient and the physician counts for more than all other factors combined. If there is a good relationship there, patients will put up with other problems."

When you're choosing questions, look to your patients for ideas. Dr. Fleming suggested creating two or three focus groups composed of 10 to 14 patients and turning some of the issues they raise into questions for your survey.

Finally, pretest the survey with a focus group. Ask a handful of patients to take it, then walk through the survey with them to see if they are misinterpreting any questions. That will help you revise your questions.

  • Distribute for results. One important question is exactly how many surveys you'll need to distribute to get reliable results. Some consultants like Mr. Seibert say that you need about 400 responses to make sure that your survey is reliable for the practice as a whole. (Expect a plus or minus 5% sampling error on each question.) Carl Cunningham, director of the College's Center for A Competitive Advantage (CCA), however, said that 50 to 100 responses will provide enough information to measure patient perceptions.

Some practices hand surveys to every patient who comes in over the course of a few weeks. The danger is that some patients will slip by without receiving a survey, or your receptionist might not give a form to patients who look particularly upset. One good way to get a random sample is to give a survey to every fourth patient who comes in during the week.

This method of distributing in-office surveys will often get response rates of around 75%, said Susan Keane Baker, a former hospital administrator and the New Canaan, Conn.-based author of "Managing Patient Expectations."

Carolyn Albert, Practice Management Associate with the College's CCA, said that many physicians have found distributing patient surveys in the exam room to be highly effective. Instead of killing time reading magazines while they wait for the physician, patients can complete survey questions about access and staff. Once they have seen the physician, she said, patients have to complete only the remaining questions about the physician and overall satisfaction.

If confidentiality is a concern, Mr. Seibert said, patients can mail the surveys back anonymously. While you should expect a 30% response rate from mailed surveys, he noted, you can bump that rate up to 45% if you send out a reminder a week later. Mailing will add to your expenses.

  • Get help. If all of this sounds rather complicated and time consuming, consider paying someone else to do the work for you.

If you go the route of consultants, rates will vary by the size of the practice, by the number or frequency of surveys, and by how finely you want the results broken down. Mr. Seibert, for example, said he would charge a 10-physician practice anywhere from $1,000 to $7,000, depending on whether the group wanted surveys annually or quarterly and whether it wanted a report on each physician or just the group as a whole.

Another option is to buy an off-the-shelf satisfaction survey. A number of professional associations offer surveys and, in some cases, allow you to compare your results with average results of other practices that have used the product. (See "Off-the-shelf products.")

ACP-ASIM's Patient Satisfaction Check Up Product provides a 35-question survey (plus some additional questions on demographics and health status) and other materials such as posters. Members pay $150 for the first physician in a practice and $125 for each subsequent physician.

Patients drop the survey into a box, and the practice sends the surveys back to the College for results to be tabulated. Your patient satisfaction scores are reported to you over time as you repeat the survey. The report also compares the results of each question to the responses that other practices participating in the program received.

The ability to compare your results against those of similar practices can help identify areas you need to work on most, and it is a big advantage to buying your survey from a consultant or association that offers such breakdowns. Be sure, however, that the comparisons are relevant to your practice. "It's vital to be compared to people who are in similar specialties and situations," said Mr. Sullivan, who creates patient satisfaction benchmarks using data from his 400 client practices.

  • Use the results. No matter how much you spend or how carefully you word the survey, it will do little good if you let the results gather dust in a drawer. "Develop a process in which at least the managers of all areas and probably all providers participate in a session where they hear the results," Dr. Fleming said. (The College's Patient Satisfaction Check Up Product includes a booklet that offers tips on how to incorporate improvements from each survey topic in its survey.)

Prioritize the issues, develop a specific plan of action for issues you want to address, assign responsibilities and develop a timeline, she said. For example, one frequent patient complaint is waiting time in reception or in exam rooms. "The first step may be to gather some information and track how long people are waiting to see if it varies by physician," Dr. Fleming said.

That's exactly what Gastroenterology Associates in Hilo, Hawaii, is doing. The three-physician practice discovered last year through ACP­ASIM's survey that too many patients were unhappy about wait times.

To determine where logjams occur, staff members now monitor when patients arrive, when they go to the exam rooms and when the physicians see them. In addition, patients are asked to arrive 15 minutes, rather than 30 minutes, prior to their appointments.

Other practices incorporate patient satisfaction results into physician pay formulas. In 1997, Cardiology of Tulsa moved from an equal split arrangement to one in which only half of compensation is equally split; 25% now is based on production and 25% is based on a combination of patient and peer satisfaction surveys.

Similarly, the 10 internal medicine practices at Brigham and Women's Hospital in Boston last year began using patient satisfaction results to drive a percentage of physician salaries, said Robert C. Goldszer, FACP, vice chair for internal medicine and director of specialty services at the hospital.

"It's a small part," said Dr. Goldszer, who from 1991 through mid-1999 was medical director of Brigham and Women's Physician Group, a 10-physician internal medicine and cardiology practice at the hospital. "What's important is that people understand this is part of their compensation. We think that will influence behavior."

Bryan Walpert is a freelance writer in Denver.


Off-the-shelf products

Looking for an off-the-shelf patient satisfaction survey? Here are a few options:

  • American Academy of Family Physicians. As part of its Vital Signs package, the AAFP provides an overview of the patient satisfaction process, a questionnaire that can be photocopied and worksheets to analyze the results. (Benchmarks are not included.) Cost: $10 for members/$15 for nonmembers. AAFP also offers a separate software package to analyze patient satisfaction results. Cost: $5 for members/$10 for nonmembers. Information: www.aafp.org/vitalsignsor 800-274-2237.
  • ACP-ASIM. The College's Patient Satisfaction Check Up Product provides 150 surveys and materials such as posters. Once results have been tabulated, the College issues a report that takes your results and benchmarks them against other internists participating in the program. You also receive additional results over time as you repeat the survey. The package includes a tip book on how to improve patient satisfaction. Cost: $150 for members/$175 for nonmembers for the first physician in a group; each additional physician receives a $25 discount. Information: www.acponline.org/cca or 800-523-1546, ext. 2600.
  • American Medical Group Association. This group offers a one-page survey that practices return to the AMGA for analysis and benchmarking. Cost: annual fee ranges from $750 to $2,500, depending on group size, and per-provider fees ranges from $6 to $12.50 for members, depending on group size. Per-provider fees for nonmembers are $65 regardless of size. Information: www.amga.org/qmr/psat/Public PatSat.html or 703-838-0033, ext. 347.
  • Medical Group Management Association. MGMA provides physicians with a patient satisfaction survey and then helps benchmark the results. The survey includes software, a scanner to read survey card information, 1,000 survey forms and semi-annual comparison reports to groups across the country. Cost: $5,500 the first year for members/$11,000 for nonmembers, $350 per year after that for members or nonmembers. Information: www.mgma.com/crahca/ ptsatis/descrpt.html or 888-608-5601, ext. 879.

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