Any healthcare provider who takes a one-size-fits-all approach to patients, does so at their own peril because they are doomed to repeat the same satisfaction outcome over and over again.  My feeling is that if you can recognize the type of patient you are working with, you have a much better chance of altering that outcome.  

In the past, both Brooke and I have written and talked to healthcare organizations about “reading” patients.  This is the process of identifying the patient’s personality type and understanding what the patient needs from an emotional standpoint.  But if the desired outcome is a positive patient satisfaction survey, reading patients is only part of the equation.  The other part of the equation is addressing the issue of who will likely be filling out the survey based on the patient’s medical situation and the patient’s behavior. 

I have created the following list of patient types (if you have others, please share), to illustrate that creating real change in your healthcare organization sometimes requires predicting how a particular patient might respond on a survey and then develop strategies to make the most of that prediction:

1. The hard to please patient – I am reminded of the nurse who said to me, “If patients would learn to be nice to me, I’d be nice to them.”  Of course, it doesn’t work that way.  Make sure staff appreciates the damage these patients can do with one survey.  Then ask them to consider how many of these types of patients they encounter each week.  The percentage should be low.  Hopefully they will come to the conclusion that extra effort to be responsive and overly-attentive will pay dividends.

2. The passive patient who is silently disgruntled – Beware of the phrase, “Everything is fine” when the patient’s body language and facial expressions say otherwise.  Don’t accept that answer if other things are telling you otherwise.  Probe the patient for feedback.  If you can’t get it from the patient, ask family and friends such as, “It seems Betty might be upset about something, is there something I should know?”

3. The submissive patient who has the family fight his/her battles – With this type, you are getting no clues of dissatisfaction from the patient but volumes from the family.  Thinking with the end in mind, who is likely to have the most input on the survey?  It is probably the family.  Focus your attention on them to make sure they are satisfied by the time the patient is discharged.  In doing so, make sure they are directly involved in the discharge discussion.

4. The happy patient who is uncomfortable commenting – These patients fall into the category of those who don’t bother completing the survey because everything was just fine.  Don’t let them get away with it!  For this type, put more effort into encouraging them to participate.  They have to be convinced that it REALLY IS IMPORTANT that they do so.  Please don’t use underhanded tactics like “begging for a five,” but tell them that the organization really appreciates as much detail as possible such as identifying staff people by name.

5. The demanding but appreciative patient – These patients keep asking and asking, but as long as their needs (or wants) are met, they are happy.  You won’t know this unless you carefully assess their response to your actions.  If you go above and beyond for them on a regular basis, you’ll have a friend for life.

6. The very ill patient – I include this type not because they are likely to respond to a survey, but because someone else might.  Again, it is important to feel confident that the family is pleased with the care their loved one has received and that their needs were met.

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What seems to be missing from the incredible interest generated by Lindsey Tanner’s AP wire story is an appreciation for how rare the “undercover patient” practice is.  Few organizations do more healthcare mystery shopping than Perception Strategies (over 50,000 to date), and yet, direct contact with physicians is a very small percentage of what we do.  Physicians who deride the practice of healthcare mystery shopping haven’t said how often they think it is being done; they just know they don’t like it!

Are we really “spies?”  One definition of spying is “to keep under surveillance with hostile intent.”  In ten years of healthcare mystery shopping, we have never been asked to “go after” a doctor.  There are elements of the patient experience that everyone has opinions about - human interactions, the facility, and processes such as wait times.  However, we have always had our shoppers avoid sharing their views on clinical care unless one includes hand washing.  They not only are not qualified, but no one would hire us to provide such a service.

According to the AMA, they are considering a recommendation whereby mystery patients don’t interfere with treating real ones, doctors are given a heads up on mystery shopper visits, and that bad reviews aren’t used as punishment.  To set the record straight, we have tried various ways over the years to creatively provide valuable feedback without interfering with patient care.  The most successful has been to seek a patient’s permission to accompany him or her during a visit.  A trained, silent observer approach allows the shopper to see and hear what the patient does, while also being flexible enough to expand the overall experience by observing other areas of the facility.

As for punishment, we have never been in favor of using mystery shops to punish staff because no real damage has been done.  Rather, mystery shops show clients what behaviors and processes have likely occurred in the past and will continue to occur in the future if they don’t take action.

Despite efforts on our own to be sensitive to physician concerns, honestly, how disruptive is it for a physician to see 10,000 patients and one of them is a mystery shopper?  Can you really call those 15 minutes with the doctor (out of hundreds of hours) a waste of resources if the hiring organization discovers several ways to improve patient satisfaction?

We believe our information should be seen as valuable to doctors because it is the same kind of feedback patients would provide if they were to take a lot more time assessing their experience and if they were perhaps a little more eloquent.  That is why the following argument Dr. Frederick made to the AMA that shoppers are healthy and therefore are not representative patients is absurd.

“One wonders how effective the secret shopper can be in assessing physician’s most important role.  If these people are not sick, frightened, tired, and vulnerable like real patients, how helpful is their appraisal to the physician who patients are frightened and vulnerable.”

Is Dr. Frederick suggesting that healthy people are less grateful, or that sick people are too weak and vulnerable to be critical?  Does that mean he only wants to hear from patients who are frightened because they will be more thankful? 

I think some physicians are naive about how consumers perceive healthcare.  There is so much more to the relationship than the physician’s ability to heal.  Most patients are attuned to what happens to them and how they are treated from the beginning of the patient experience to the end.  In fact, many consumers of healthcare understand the healthcare process better than physicians do because they are exposed to all facets of the experience of which the physician is a small, albeit critical, component.  And one would think they would want to know how their “business” is being perceived.

If you work in the healthcare industry and comment on one of my blogs, you will be eligible to win a free Keep the Customer:Healthcare Edition customer service training game valued at $349.  This offer is good until July 31, 2008.  After you have commented - something constructive, please - leave your email address with the comment and I will contact you for shipping information.  Thanks.

Note: Comments were requiring registration but they are now open.  Sorry for the mix up.

Has your organization been turned on to the simplicity of the Net Promoter Score (NPS) yet?  If you’re not familiar with it, it is a tool that allows you to come up with one score for customer satisfaction that can be easily tracked and understood.  It uses the likelihood of recommending survey question (on a ten-point scale) and categorizes respondents as promoters (9’s & 10’s), passives (7’s & 8’s) and detractors (0’s to 6’s).  You then subtract the percentage of promoters from the percentage of detractors to arrive at a score somewhere between 1 and 100. 

A cover story article in the June Fortune Small Business has sort of re-sparked an interest in Frederick Reichheld’s book The Ultimate Question.  I first started using the NPS in early 2007.  It never really caught on with the hospital I initially introduced it to.  The article mentions that NPS is perhaps too simplistic, but I found that this hospital was still trying to grasp patient satisfaction and was not ready for another metric.  Too bad, because it is a metric corporate America seems to be latching onto. 

For example, I was talking to a regional manager at Panera Bread last year about their business and he threw out what their NPS score was (as if I should know).  Well I did know, but I don’t recall his score.  But I do remember getting an immediate sense of where his stores stood with customer satisfaction. 

As a tool, the most beneficial thing about NPS is what Reichheld calls the permission clause.  This is a proactive effort to follow up with customers to obtain actionable information.  I still remember years ago having this vision in my head of my boss the hospital CEO crossing his fingers before receiving the quarterly patient satisfaction data.  I asked myself then, and I ask you now, what is your detailed plan for moving the numbers?  And now that they’ve made it even easier by boiling it down to one number, the question remains, what are you going to do to get it to move?

I had my annual physical exam yesterday.  My doctor knows what I do for a living so I suspect our conversation went in a slightly different direction than most.  We discussed increased consumerism and Angie’s List’s foray into healthcare which he had no problem with.  But the one thing he said that sticks out was his take on pay for quality. 

I hadn’t thought about what it means to base physician reimbursement on the doctor’s ability to convince another human being to take care of him or herself.  Is that fair?  As the doctor suggested, won’t physicians start cherry-picking their patients based on lifestyle choices?  You can imagine them saying, “Before I accept you as a patient, get on the scale.”

I was listening to a local public radio snippet on healthcare the other day and they were talking about colon cancer and how preventable it is based on lifestyle choices.  I had a colonoscopy last year at the urging of my doctor.  Under a pay for quality scenario, if I ignored his urging he ultimately would get dinged if i get colon cancer.  Maybe the answer would be for him to create a personality test to determine if a new patient is likely to follow instructions.  If not, they’re out.   

As my doctor stated, it is very complicated issue; so I don’t feel bad for not having large-scale solutions (just like the politicians).  But I think that in looking for answers we have to look at both sides - patient and provider.  When a healthcare provider throws up his or her hands and says, “What more can I do?” the answer is to think highest common denominator, not lowest.�

One of our healthcare mystery shoppers made a call the other day to a physician referral service. She was asking if she could have her cousin transferred to their hospital from another hospital nearby. After requesting all the necessary information, the CSR explained that they have a Patient Transfer Department. He said that they work with the doctor at the other hospital to get the patient transferred.

The CSR then asked if the caller thought the doctor at the other hospital would work with them. The shopper said she thought so. The CSR then asked what made the cousin want to transfer. The shopper explained that her aunt feels more comfortable at his hospital. He gave the shopper the direct number to the Transfer Department. But before he transferred the call, he said, “Let me get you transferred over there and I pray that everything goes well with your cousin.”

The shopper writes, “Overall I am completely satisfied with my call to this hospital. The CSR was very friendly and professional. He ended the call very sweetly. That made me feel like he really listened and cared about my situation.”

A review of the standards evaluated for this shop pointed to a less than perfect experience - quantitatively speaking. And yet, the power of the phrase, “I pray that everything goes well with your cousin” overwhelmed any minor infractions. The CSR “pushed a button” with the caller. In a single phrase, he expressed concern for the patient in a very personal and heartfelt way.

Without asking the shopper, I assume the word ‘pray’ had a great deal to do with her final assessment. The CSR could have said, “I hope it goes okay” or “good luck,” but he didn’t. Even the implication that he would consider praying for the patient takes his empathy to a whole new level. While the hospital represented in this shop is not a Perception Strategies’ client (it was a competitive mystery shop), I believe they are a religious-based organization. There is not enough here to suggest that the hospital encourages staff to use the word pray as part of their service doctrine. But my hope is that they do!

People desperately want healthcare providers to care for them on a spiritual level. A good share of the hospitals in this country were founded for the sole purpose of carrying on Christ’s work. I believe healthcare needs to get back to its spiritual roots in order to more effective convey its desire to care for patients. I hope to be writing more on this important subject in the future.

I was explaining the benefits of healthcare mystery shopping to a hospital marketing executive a few years ago, and was pleased that he finally came to the conclusion, “That would be the logical next step, wouldn’t it.”  Thankfully his assessment was realized and he became a client of ours.  As someone who has made a career of providing healthcare mystery shopping, I (of course) believe he was right.   But now with HCAHPS and increased consumer advocacy, it is more true than ever.

The elevated importance of patient satisfaction data means that as the data is digested, more and more questions will arise.  For instance, a survey will tell you there is a concern with the friendliness of the radiology staff.  Instead of creating a broad brush customer service program for the Radiology Department, the logical next step is to determine how the department is being perceived by end-users, what the department’s behavioral weaknesses are, and who on the staff is exhibiting those behaviors.

Together patient satisfaction data and mystery shopping can begin to focus on meaningful solutions that cause providers to say, “We know from patient satisfaction there is a problem and from mystery shopping we know what that problem is and who is primarily responsible.”

While I advocate that managers look for coaching opportunities by observing their employees in action, expecting them to alter the service culture is less likely since - for the most part - they created the culture.  Because mystery shopping is strictly consumer perception, it provides an unbiased view of a department or organization’s culture.  This gives managers a third party perspective that leads to increased coaching opportunities.

 In ten years of doing healthcare mystery shopping, I believe the two most valuable uses of this research are: 1) mystery shopping the competition, and 2) allowing us to report on individual employees.  Call us spies, many do, but it is critical that you know what your competition’s culture is.   For example, what do they believe in and how is it transferred to the patient?  Can the anecdotal stories you’ve heard be verified?

We have also seen a great deal of value from conducting evaluations of individual employees.  For a number of reasons - cost certainly being a factor - this works best in a departmental environment.  We first set a minimum number of shops we are going to conduct of a certain employee.  We then determine the employee’s schedule to increase the likelihood we will reach him or her. 

This allows us to give a manager an apples-to-apples comparison of each employee as it pertains to specific standards.  For instance, is Cindy more likely than Jeff to greet patients immediately (setting up a coaching opportunity)?  Or, Does Jeff do a great job of cross-selling services and should be commended? 

Lastly, healthcare mystery shopping gives managers concrete examples of the specific behavior that “turns patients on.”  This sets up the perfect opportunity to present to staff the behaviors the organization would like emulated while giving kudos to the employee who displays them.

I was doing a little channel surfing the other day and happened to catch the tail end of Secretary Mike Leavitt’s comments to the Association of Healthcare Journalists on C-Span.  The head of Health and Human Services was announcing the launch of the Hospital Compare initiative we in healthcare have been preparing for what seems like an eternity.  While I find the site easier than expected, I’m not as convinced as Secretary Leavitt that the “new generation of involved consumers” will actually use it. Of course media like the NY Times will have fun with it for a time, but will it have any staying power. 

Here’s my concern, at what point will consumers seek out this information? Will it be after their doctor has already scheduled surgery? Will it be when they are healthy and have nothing better to do on a rainy day? I think the answer is no to both. I might consider comparing my hospital to the Cleveland Clinic, but I can’t figure out how to do that yet. Secretary Leavitt did say that he thought the information would be incentive for providers to create greater value for consumers.  I agree with him, and I’m guessing that was their intent all along.

I thought we would start this blog by weighing in on the Angie’s List announcement yesterday that they are adding healthcare to their “list” of services they evaluate. In the Indianapolis Star article (Angie’s List is headquartered in our hometown) Deloitte Consulting’s Linda Heitzman said, “It’s a great extension of the consumer movement and more evidence of that in health care. We’re really making the shift from ‘patient’ to ‘consumer.’”

I couldn’t agree more. Healthcare has to stop thinking in terms of what they do (technically) and begin focusing more on how they do it (respectfully). For instance, the following opinion of Dr. Jon Marhenke, president of the Indiana State Medical Association, points to the ‘what’ and ignores the ‘how.’ According to the Indy Star article, “Marhenke said that what goes into practicing effective medicine is complex — an art as well as a science — and this approach (Angie’s List) tends to compare it to a routine task such as installing a new sump pump.”

Unfortunately, it appears there is going to be a little kick-back to the consumer movement. Marhenke’s quote suggests that consumers are too simple-minded to make such a complicated decision and that it is best to leave well enough alone. And yet it is inevitable that healthcare will come to realize that the comparison is not art/science versus a sump pump; rather, it is about not accepting how providers treat consumers. Patients care most about what they know, and that is how they feel – not just physically, but emotionally, and not what they don’t know – medicine. They are not going to tolerate being belittled by providers hiding behind the mystifying cloak of art/science.

Consumers have always sought the opinions of others to select their providers. So what is the difference between Angie’s List and word of mouth recommendations by family and friends? Same animal - just a wider net. When someone says, “I think you ought to go to Dr. Smith,” is it because Dr. Smith has the complexities of practicing effective medicine down pat? Or is it because Dr. Smith’s nurses are pleasant and caring, the staff is efficient and the doctor has a decent bedside manner?

Because we service the healthcare industry, we understand and appreciate that making an effort to affect consumer perception is not natural for many providers. However, it is my belief that the generation of baby-boomers who launched the consumer movement will make it hard on those who fight the wave rather than ride it.