American College of Physicians: Internal Medicine — Doctors for Adults ®

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Want patients to keep coming back? Ask for their input

Scoring well on patient satisfaction surveys can improve care and boost pay-for-performance rewards

From the January-February ACP Observer, copyright 2006 by the American College of Physicians.

By Janet Colwell

As physicians scramble to put measurement and reporting systems into place, it's easy to forget that quality improvement is more than just charts and numbers. Finding out how your patients experience your practice—and what you can do to enhance that experience—are critical parts of delivering quality care.

Even without pay-for-performance programs, improving patient satisfaction makes good business sense, said John W. Phillips, president of PivotHealth LLC, a health care management and consulting company in Brentwood, Tenn.

"Many areas of the country have experienced significant increases in the number of doctors in the last 10 years," said Mr. Phillips, who spoke at a recent Medical Group Management Association conference. "Competition is real."

At the same time, a growing number of medical groups are pegging physician bonuses to their scores on patient satisfaction surveys—a tack taken by more health plans in pay-for-performance programs as well. Survey results can help flag practice areas that need improvement and target necessary changes. Those changes can lead to better patient retention, higher pay-for-performance rewards—and less chance of litigation.

"If you're willing to look at what a survey tells you about your business and do something about it," Mr. Phillips said, "you'll do a better job of keeping the patients you have instead of constantly losing the old patients and finding new ones."

Survey design

Patient satisfaction surveys typically contain about a dozen questions and canvas patients who have visited the office within the past 90 days. Patients with mental health problems, alcohol- or drug-related problems, sexually transmitted diseases or other sensitive diagnoses should be omitted.

A survey should cover every aspect of the patient's experience, from the friendliness of staff and the comfort of the waiting room to how long patients must wait to see a doctor as well as the quality and thoroughness of care. Surveys should target a database of eligible patients for each provider, with the goal of getting 30-40 responses per physician. Always try to complete the same number of surveys per provider.

Besides the standard subjects covered by all patient satisfaction surveys, consider including topics that pertain specifically to your practice. Is there enough parking? Are your location and hours convenient? While most questions should require choosing one among a range of answers (from "poor" to "excellent"), you should also include one open-ended question, asking patients how staff could improve their experience with the practice.

"Focus on things that get the most bang for your buck," Mr. Phillips advised. "If you're doing the survey to learn about your business, the most important thing is to find out about patient loyalty. If you're doing it as part of a pay-for-performance plan, you will want to focus more on traditional patient 'dissatisfiers' that HMOs care about, like appointment availability, wait time or time spent with patients."

Phone, mail or e-mail?

Consider the pros and cons of different types of surveys before deciding what's right for your practice.

For instance, live telephone surveys conducted by trained staff deliver the most accurate results, Mr. Phillips said—but they will usually cost somewhat more than other methods.

Why pay more for a live phone survey by an outside company? Reliability is the No. 1 reason, Mr. Phillips said. Survey companies typically have a computer randomly select when people are called, and calls are made until every physician has the same number of surveys completed. When you mail or hand out forms, on the other hand, the number of responses depends on how many patients choose to return the surveys, and the responses are not nearly as random as with a live phone survey.

Most phone survey companies also can do the survey in two different languages. And, phone surveys typically get a high response rate, between 85% and 90%, while handout and mail-in surveys will normally produce a response rate of less than 25% of targeted patients, thus reducing the survey's statistical reliability.

"Patients tend to agree to take the survey because they appreciate getting the call," he said. "That gives you a good cross-section of patients and it's good public relations." Telephone surveys take about four months from start to finish, which includes creating the survey, extracting patient data, training survey staff, making the calls and analyzing the results. And according to Mr. Phillips, surveys should be repeated every six months to track improvements.

Automated phone surveys are a less-expensive alternative and can deliver the same number of responses per physician, he said. However, they lack "the human touch," he noted, and typically yield fewer patient responses.

Written surveys are even less expensive but are often the least effective, he said. If conducted in the office, patients may be less willing to be honest, while staff may be biased toward handing surveys only to those patients with whom they have a good rapport. Mailed surveys tend to present a skewed view of patient satisfaction, with the bulk of responses coming from either angry patients who had a bad experience, or happy patients whose physicians urged them to return the form.

E-mail is the cheapest way to go, Mr. Phillips noted. Electronic responses are easier to display and to process than written forms or recorded calls, and many patients are more likely to respond to e-mails than through the mail. However, e-mail probably isn't the best option for internal medicine practices with a high percentage of Medicare patients, he added, as older patients are less likely to have e-mail access or feel comfortable using or trusting computers.

Using the data

The more practices use surveys, the more effective their quality improvement efforts will be, and the more you can tie individual compensation to patient satisfaction. What may be perceived as a negative by office administrators, for instance—spending more time during appointments—can be a big plus for patients.

"The 'plodder' might not see as many patients per hour as the administrator would like but he's making patients happy because he's taking more time with them," Mr. Phillips explained. "A lower patient turnover will help you with pay for performance—and happier, more compliant patients also mean lower malpractice risk."

Of course, physicians have little or no influence on some areas covered by a survey. To allow for this, survey questions should be weighted with a "physician influence value" from zero to five, with zero indicating that a physician has little or no ability to affect the result and a five signaling that the physician can have a substantial impact.

A question on how a patient would rate the comfort of the waiting area, for example, merits a physician influence value of zero, while a five might apply to questions about a physician's skills or personal demeanor. (See, "What should you ask about?")

A final physician scorecard would list each question showing the physician influence value, the average grade and each doctor's score (average grade multiplied by the influence value for that question) out of the maximum possible points. The scores are totaled and divided by a "constant" (the sum of the multipliers used to adjust the physician influence factor for each question) resulting in a final score ranging from the lowest possible score of "one" to the highest possible score of "five."

Practices can then slice and dice the data in a number of useful ways, he said. For example, a bar graph could display how the group as a whole rated by question or show the distribution of total scores. Large or multispecialty practices might break out individual physician scores compared to clinic or specialty averages, or rank physician grades by specialty.

With the bonus dollars available from "high satisfaction scores," a practice might be more likely to proceed with needed operational improvements, such as sprucing up the waiting room, as indicated by the survey results.

Just good business

Whether or not you participate in pay-for-performance programs, measuring patient satisfaction is a smart way to grow your practice and retain patients, said Mr. Phillips. Even one negative experience can affect revenue, because unhappy patients tend to influence their friends and relatives.

"Doctors are trained as scientists first," he noted. "Some have the ability to show patients that they care but most have to learn. What the patient satisfaction survey does is tell you which physicians need help in improving the patient experience."

In addition, some insurers consider individual physicians' patient satisfaction scores when assessing a physician's risk of liability suits, he said. "It's worth going to your carrier to see if they will participate with a percentage reduction in your premiums."

Ultimately, satisfaction surveys remind a group that patient care is at the heart of its business, something that can get lost in the administrative shuffle.

"While we're concentrating on efficiency and correct billing practices, patients sometimes get lost," Mr. Phillips said. "While the doctor is trying to get his reports filled out on the computer, the patient might be thinking about going somewhere else."

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What should you ask about?

The typical patient satisfaction survey covers these areas:

  • thoroughness, carefulness and competence of physician
  • interaction of doctor with patient
  • quality of nursing care
  • friendliness of reception
  • comfort of waiting area
  • length of wait in the waiting room
  • length of wait in the exam room
  • appointment access
  • telephone help
  • patient loyalty
  • overall impressions
  • suggestions for improvement

Source: PivotHealth LLC

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