"Effective Patient and Referring Provider Satisfaction Surveys"

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"Effective Patient and Referring Provider Satisfaction Surveys"

It's more than simply asking a few questions.

Gil Weber, MBA

Adapted with permission from Administrative Eyecare
American Society of Ophthalmic Administrators
© Copyright 2003. All rights reserved.
Spring 2003


It's unfortunate that physicians and practice administrators sometimes are unaware when patients leave the office dissatisfied with the service received. Perhaps they will keep the upset to themselves and never return to the practice. Perhaps you'll never know why a certain patient and perhaps the entire family requests a transfer of their records to another ophthalmologist.

Even worse, patients may tell 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 carrier or HMO as well as local employers' human resources departments. The bad word can even travel across the country to third party vision plans.

If a patient files 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. It may not be pleasant, but at least it's structured.

A New and Ominous Threat

Today, however, there is a new and potentially ominous threat to your reputation. Several websites are available through which disgruntled patients can vent their anger at you -- in public and, essentially, unconstrained. Although you might not know that the patient is unhappy, the rest of the world could know. And that should concern every practice.

Two Internet complaint sites are Complaints.com (www.complaints.com) and Rip-Off Report.com (www.ripoffreport.com). There are several others. Although no site is yet a repository of many complaints against physicians, it's clear they have the potential to create headaches and problems. You should know that these sites typically do not check the validity of complaints -- they only provide a forum for "venting." In many cases they allow anonymous postings and confirm only that the complaining party used a valid e-mail address.

Unless the complaining party provides complete physician contact information, some of the sites make no effort to contact the physician against whom the complaint's been lodged. Consider this -- you may never realize a complaint has been posted on a public forum.

It's worthwhile to look at some of these complaint sites to see just how irate patients can get. They make it clear that every physician and administrator needs to do a better job understanding why patients feel good or bad about a physician, the care they've received, or the staff with whom they've interacted.

Thus, it's essential to create mechanisms that allow your patients to provide the practice with feedback so that you're then able to take appropriate steps to ensure that all patients leave the office satisfied with their care and confident in the doctor. As Samuel Johnson said in the Life of Johnson, "Knowledge is of two kinds. We know a subject ourselves, or we know where we can find information upon it."

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 asking this.

Too often, patient feedback from surveys proves marginally useful. Although for some the results are enlightening, for many more the results are unclear, or hard to interpret. Often, if the return rates are low, there are no meaningful results on which change can be made and then measured.

The fact is most surveys have serious design flaws. They ask the wrong or ineffective questions. Typically they'll ask only the most obvious questions -- the answers to which are probably predictable and not very enlightening. Other surveys ask a few good questions but bury them in the middle of far too many unfocused questions.

Thus, it's essential to ask the right questions and to word them to elicit useful responses. A question that gets you no useful information is space wasted. Here's an example of a poorly written question from an actual survey:

Are our fees reasonable compared to other eye doctors? ___ Yes ___ No

Think about the patient, say John Doe, and factors that might influence his answer. If he's from an HMO he may be in your office simply because you were chosen by a primary care physician, another ophthalmologist, or an optometrist. Perhaps he had no input.

Let's say his only responsibility today is a $15 copay. On what basis does that patient make any judgment that your fees are or are not reasonable compared to those of other eye doctors?

Or assume that he's a private pay but his previous exam was 3 years ago from an optometrist. He paid $65 back then and your fee today is $115. It's an apples to oranges comparison, but the patient may not know that. If he answers "no" how valid can that answer be?

So, assuming your patients do understand the difference between ophthalmologists and optometrists, you might instead consider a question like the following.

If you had any out-of-pocket expenses other than co-pays, were they reasonable compared to those of any other ophthalmologist you've seen in the past 2 years for similar services? _____ Yes? _____ No?

Please explain                                                                        

I'm not saying this is the right question for every survey, but look at the difference in how the question is structured. Each question must elicit a measurable response to a narrowly focused issue. It gives you a way to compare apples to apples.

The Key Components in an Effective Survey

The Right Questions

The first key component of an effective survey is to ask the right questions. There are 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 inquiries to probe into and measure performance in these traditional areas. Following is a partial list:

  • Was it easy to make an appointment?
  • Was staff courteous on the phone and at check-in?
  • Was the waiting room clean? The examination room?
  • Did the doctor and staff answer all your questions?
  • Was check-out quick, easy, etc.?

Don't devote valuable survey space to questions that should never be necessary. For example, some surveys ask: Was our selection of magazines adequate?

Your magazine selection should always be adequate and current, and you should have systems in place so that you never have to think about asking this question. If your patients are finding out today from your magazines that Jay Leno has just replaced Johnny Carson as the host of the Tonight Show some patients will feel insulted and disrespected by an inattentive physician who doesn't seem to care about the most basic of waiting room comforts.

The second and often unasked set of questions can be even more important. These are questions that can reveal hidden issues more significant that you might imagine -- issues you'd never appreciate unless patients were given the chance to respond.

Here you're thinking outside the traditional box. You're looking to find small sources of irritation or small pleasures that make patients happy. You might craft some questions to probe into these areas. Following is a partial list:

  • Did staff provide concise directions to the office?
  • Was there adequate signage? Was it easy to see from the street?
  • Was there adequate parking? Was it close to the entrance?

Whatever you ask, it's essential that your survey includes space by each question for patients to vent or praise. You might be surprised by the unexpected answers you receive when you give patients an opportunity to tell you what's on their minds.

For example, Utah-based consultant Derek Preece tells of a survey that revealed patients were upset by a dirty fish tank in the reception area. Apparently they liked watching the fish, but were a bit put off that nobody seemed to keep things clean. Fish tank cleanliness was not an issue that showed up on the practice's radar screen before the survey, but it certainly was after that.

Think about your reception area. If you're the physician, when was the last time you came in the front door rather than in through a rear entrance? When was the last time you stopped to observe the area from which your patients get their first impression of your office?

Georgia practice administrator Steve Robinson tells what happened after an office remodeled and installed white counter tops in the areas where patients stood when checking out. The white counters were installed with the idea that they presented a clean, professional, medical office image.

However, Robinson learned that the patients were not so pleased with the new look. As one patient put it, "The counters look very nice, but when we're standing there the bright lights from overhead reflect off those shiny white countertops directly into our eyes (which are dilated). And that hurts!"

Nobody had made that connection during the design stage. It is amazing what can be learned from patients if only they're given a chance to voice their opinions.

Create Expressive Means

The second key component in an effective survey is creating an expressive means for patients to rate specific performance. Asking yes-or-no questions returns the least useful information because it presents a situation as black or white. There's no qualification or explanation contained in that simple response.

Numerical responses (e.g. 1-5, 5 being best) or descriptive responses (e.g., poor, fair, good, very good, excellent) are better than yes or no. However, they're still problematic because, for example, a "poor" response doesn't tell you why the patient feels that way or give you any hints on how or whether to make changes.

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 "poor," 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 that asks the patient to expound upon any unfavorable response or on an 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 positive.

Appropriate and Timely Action

The third key component in an effective survey is to take appropriate and timely action based on the survey results. This does not mean implementing every change suggested by your patients. It does mean discussing the results with physicians and staff to determine which changes, if any, can and should be made. You must discuss exactly how you'll make the changes happen.

Certain suggestions are slam-dunks for action. For example, you must have adequate, outside signage if patients are to find your office. If you don't, assign someone the task of making it happen -- immediately. The issue is too important to push off for future consideration.

It's worthwhile to let your patients know when you've made changes based on their input. For example, if you extend your hours based on patient requests or if you start up a payment finance program, tell your patients. You might post a sign in the lobby, or announce changes in your patient newsletter. However you do it, give your patients a sense of empowerment. It's a great loyalty builder.

Good survey results and enlightening information do you no good if the practice takes no corrective action. However, that action needs to be responsive rather than reactive. There's an important difference between the two.

Assume you've surveyed and collected a lot of good information. You met with physicians and staff and made some changes based on patient input. It's been awhile, and you decide it's now time for another survey.

At this point, many practices make a critical mistake. They send out a new survey but change it significantly -- asking fundamentally different questions. That effectively leaves them back at square one since these new questions don't measure how well or if the practice improved from the previous survey. And they don't measure whether the changes had any effect on patient satisfaction.

Measure Performance Change Over Time

The fourth key component to an effective survey is measuring performance change over time -- carefully re-examining progress on key issues from previous surveys. To do this you must measure how well you've addressed those problematic issues that were identified 3, 6, 12 months ago -- whenever you collected the information. Although you should also identify new issues and add some to the new survey, the core questions must remain intact in order to assess how you've done.

It's not necessary to survey the same patients to measure progress. Because you're always seeing a new mix of patients, it's probably impossible to resurvey the same group.

But that's okay because it's reasonable to assume that if "doctor inattentiveness to my questions" or "dirty washrooms" came up often as patient complaints 6 months ago and you have not effectively addressed those matters, a different group of patients will frequently identify those problems on a subsequent survey. You'll then know you have not done enough to improve patient satisfaction in those areas.

Similarly, if the matters have been addressed effectively, patients surveyed in the future probably won't bring them up many times, if at all. You'll know you have made progress.

Exactly what determines how much progress is sufficient for you to consider a matter resolved is a practice-specific decision. For example, you might decide that any survey question receiving an average score of 2.9 or less on a 5 point scale is one that needs attention and follow-up review. Or you might decide that any question receiving more total "fair" and "good" responses than the total of "very good" and "excellent" responses needs examination and follow-up.

Other Points in Survey Design

Also consider the following points when designing and implementing a patient satisfaction survey:

  • Keep it short, preferably 1 page (2 sided) to encourage replies.
  • Keep it succinct. Write concise questions to solicit revealing answers.
  • Provide a self-addressed, postage-paid envelope or a fax number for replies if it's a take-home survey.
The Most Important Question

Always leave space at the end for the most important question:

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

The answers you receive to this may be the most revealing on your survey. Through this question, you'll learn about those issues you never realized were important to your patients. You will see how different your radar screen might be from your patients.'

In another real-life example, a pediatrics-only practice conducted what was really a "parental satisfaction" survey. The practice anticipated that the one issue it would hear about over and over was that the schedule always seemed to fall behind, and patients were rarely seen at the scheduled time. Fortunately, in addition to all the commonplace questions, the practice was smart enough to ask "the most important question of all."

The answers were eye-openers. The practice was surprised to learn that its anxiety over parent complaints about their child not being seen on time was unfounded. In fact, the 3 most important reasons why parents liked coming to this pediatric practice were as follows:

  • There was plenty of convenient parking. As long as the parents did not have to drive around and around a parking lot with crying children searching for parking, they did not mind waiting a few extra minutes for the appointment.
  • There were plenty of soft (noiseless) toys and stuffed animals in the reception area. As long as the kids could play and were not crying, the parents did not mind waiting a few minutes.
  • There was a cookie cart in the reception area stocked with fresh-backed cookies. As long as their children were happy and quiet, the parents did not mind waiting past the scheduled time.

Thus, a recognized concern about running late proved not to be as desperate a matter as feared. Successfully addressing the issue would not require anything as monumental as adding staff or another physician. That fact was made clear only because the survey afforded the parents an opportunity to tell the practice what was most significant to them.

Customizing the Survey to Patients

As shown in the previous example, you must customize your survey to suit your demographics. As each practice's patient base can be quite different, even among practices in the same city, every survey instrument needs to be constructed with that in mind.

Another example: A few months ago I met with 4 Cuban-American ophthalmologists in Miami. Not surprisingly, their patient bases were overwhelmingly Cuban-American. As we discussed patient satisfaction, I asked them whether they addressed waiting time on their surveys.

"Oh, no. Not with our patients," I heard from all 4. I assumed that meant that their practices ran on schedule, but that was not the case. All of the ophthalmologists said that their waiting rooms were typically full of patients waiting to be seen.

I asked them why did they not consider this to be a problem? Their answers, all the same, surprised me because they revealed just how different things can be practice to practice. I was told the following:

"We don't ask that on our surveys because Cubans expect to wait in the doctor's office. It's part of our culture. If patients go into a doctor's office and the waiting room is full, they think, ‘This must be a good doctor – so many people are waiting to see him.' On the other hand, if there are very few people in the waiting room then there's the perception that maybe the doctor is not so good. And so the patients expect to wait in a busy practice, confident that they will be getting the best care when their time comes."

Interesting, isn't it? Whereas long waiting times seem to be a vexing problem for many if not most practices and their patients, it wasn't even on the radar screen for these physicians and their patients. I suspect it would be different for a practice in another part of the country with a significantly different patient base and patient expectations.

The moral of that story is to know your patients before designing your survey instrument. Even if you do, be prepared to be surprised.


The Ultimate, Simple Patient Satisfaction Survey

Walt Underwood, an Atlanta practice administrator, offers this as a simple, effective survey you can conduct as a patient is preparing to leave the office.

1)    Were all of your questions answered today? If the answer is "no," Underwood says to take care of the matter right away or you'll lose that patient. He also suggests asking the question before you ask for the patient's money.

2)    Based on your visit today, do you expect to return to our office for future eyecare?

3)    After hearing the patient's response to #2, ask: What more could we do to be sure of continuing as your eye care provider?


Referring Provider Surveys

As with patient satisfaction surveys, you'll want to design an instrument that includes measures of what's important to those you're surveying. Think about designing your survey with the following in mind:

  • Some doctors send us lots of referrals. Clearly, they like us already. What are we doing right that's earned their trust, and how can we capitalize on that?
  • Some send us a few referrals, but not a lot. Those doctors sort of like us, but not enough to send us more or most of their referrals. What do we need to do differently to get more of their referrals?
  • Some don't send us any, or used to send us referrals but no longer do. What are we doing wrong that 's lost their trust entirely or that's keeping us from having an opportunity to build trust? (Practices in this last category may not respond to a survey that comes unexpectedly in the mail. It may be necessary for your practice administrator to survey the referring practice's administrator by phone.)
What to Ask; What Not to Ask

You should not have to ask certain questions. For example, you should not have to ask,

Do you get our follow-up reports on your patients in a timely manner?

This should never be an issue; it should be automatic. No referring provider should have to consider it a factor in why he or she does not send you referrals. Still, many ophthalmologists do not send timely reports to their referring doctors, so this might be a necessary question until you're confident it's no longer a problem.

You should be able to focus on questions that will probe into this key concern:

Does your staff consider it easy to work with our staff?

Think about how important this concern is. It's essential to have a good working relationship if there's to be an opportunity to grow the referral base. Consider how revealing it would be to learn from an optometrist or primary care physician's office manager the following:

"My staff complains that your staff consistently treats us with an arrogant attitude. We're constantly left on hold for what seems an eternity. Our patients can't get in within a reasonable amount of time, and when my staff says it's urgent they're constantly questioned and made to feel as if we don't know what we're doing.

"The care you provide is excellent, but it's such as hassle dealing with your staff that mine begs the doctor to refer our patients elsewhere. And we end up doing that a good part of the time just to avoid the frustration and ‘attitude.'"

When you receive an answer such as this, a light bulb should illuminate over your head. Suddenly, you will understand why things are the way they are and you'll have clues on how to fix the problems.

It Can Be Done

Although preparing a useful, beneficial survey may seem daunting, you will succeed if you ask carefully focused questions that allow respondents to provide measurable responses and to tell you what is on their mind. The responses to such surveys will improve patient satisfaction and referring provider satisfaction and, thus, the bottom line.


Gil Weber, MBA, is a practice management and managed care consultant based in Viera, Florida. He is the former Director of Managed Care for the American Academy of Ophthalmology.

This article is based on his presentation at the American Society of Ophthalmic Administrators annual meeting in Philadelphia, June 2002.

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