In the era of Yelp, Facebook and online forums, where patients can report anything at all to the Googling masses; where your competitive advantage partially rests on patients’ perceptions of your listening, caring and respect, gathering detailed, objective, comprehensive and actionable accounts of patient experiences are even more important than ever. The usual research methods of focus groups, surveys family councils and rounding, etc., help in various ways, but they don’t tell the whole story of the patient experience. To do that requires a very special kind of knowledge and insight that can only be acquired through multiple and comprehensive patient experience accounts or exhaustive direct observation of people and processes. It’s why service industries such as hotels, airlines and restaurants use Mystery Shoppers to evaluate the customer experience. Today, mystery shopping is a 2 billion dollar plus industry. However, only a small amount is healthcare’s share, perhaps because its methods, benefits, opportunities and/or perceived threats are not widely understood. Whether that may be changing is unclear.
In today’s world of Facebook, Yelp, online communities, forums and rating websites, there are plenty of opportunities for patients to communicate their complaints and opinions publicly about their medical experiences — both good and bad. Yet, for the most part, patients tend to reserve their feedback for family and friends, unless specifically asked.
Barriers such as…
- Public website criteria for critiques
- Physicians’ particular sensitivities about their reputations (e.g. requiring that patients sign agreement promising not to post comments on public sites, even though these agreements may not be enforceable), and
- The “risks” to dissing providers publicly, or even, conceivably, being sued
can be deterrents to the public communication of patient complaints
In addition to the above barriers, there are the deterrents of time and energy. Creating an effective factual, verifiable description of your problem or complaint, searching for the appropriate website, or composing a letter to the hospital president, the physician or to the clinic manager take too much time, energy.
A Personal Story
I’ll never forget my experiences a couple of years ago when my husband had a life threatening bout with MRSA/sepsis. In an earlier blog, I mentioned a few of the particulars of our experience in the registration/triage areas of the Emergency Department before my husband was admitted to the hospital. But the story didn’t end there. Although he went on to be seen by a wonderful ED physician who suspected the seriousness of my husband’s condition, and to have excellent doctors in the hospital who put him on the road to recovery, when my husband was discharged 17 days later, late in the day, with a PIC line and orders for IV antibiotics twice a day from a home infusion provider — things fell apart. No antibiotics were delivered. No nurse was assigned by the home health provider to administer the first three IVs, or teach me how to do it. How did this happen?
Unbeknownst to us, the infusion company was confused about my husband’s unusual drug coverage and came to the erroneous conclusion that he had no coverage. As a result, the infusion company did not deliver the antibiotic that was ordered. Then the staff member responsible for verifying his insurance failed to inform the company’s care coordinator, the hospital or us about the problem before discharge. To make matters worse, the infusion company did not make arrangements with an approved home health company to provide the nurses who would manage my husband’s care or administer the first dose of antibiotics.
Faced at home with this stressful situation, the natural response of most patients and families would be to call the primary care doctor and/or return to the ER. But, it was evening, and my husband refused to go back to the hospital. Rather than fight that battle right then, I started making phone calls.
Fortunately, because of my prior experience in hospital management and some (limited) understanding about insurance coverage, I was able figure out whom to call, what questions to ask, what to say and what to demand. Nevertheless, it took an enormous effort on my part, including multiple phone calls, pleading, offering to pay cash for the medicine, and even screaming at people to persuade the infusion company’s regional manager to approve having several doses of the antibiotic delivered and to get a nurse from the home health company to our home late that night.
With the final ED – CAHPS survey (The Emergency Department Consumer Assessment of Healthcare Providers and Systems) expected to become mandatory sometime in late 2015 or early 2016, now is the time for hospitals to make sure they have sufficient, in-depth, feedback about patients’ perceptions of their experiences in their emergency department. The survey from CMS will assess information about the patient experience during arrival in the Emergency Department, during care, and after being admitted to an inpatient unit or discharged from the ED.
More specifically, the final surveys will ask questions about how quickly patients receive initial care, the perceived quality and timeliness of communication with nurses and doctors, wait times, medication and pain handling, interpreter services and discharge instructions — plus the overall rating of care and likelihood to recommend the hospital to others. The Centers for Medicare & Medicaid Services (CMS) is still testing the draft surveys.
Similar to HCAHPS on the inpatient side, CMS’s goal in developing the Emergency Department version of CAHPS is to better understand the ED experience from the patient’s perspective, allow for objective comparisons of the care that patients receive, and improve the quality of Emergency Department visits across the country. Likewise, a portion of Emergency Department reimbursement is expected to eventually be tied to the hospital’s ED-CAHPS scores.
The research methods that produce the richest insight into patient satisfaction and the patient experience tend to be qualitative – e.g. mystery shopping, ethnographic studies. Qualitative methods can be messy, harder to analyze and less conclusive than quantitative research, but they often provide abundant, detailed information about systems and behavior not uncovered by quantitative methods alone. When patients tell you in their own words what happened, how they perceived what happened and “why” they felt the way they did, powerful insights and actionable information emerge.
Which Technique Should We Use?
Mystery shopping — Mystery shopping uses incognito “shoppers” posing as real patients to provide detailed feedback about their experiences. The mystery shoppers make surreptitious notes about each interaction as it occurs. Afterwards, they prepare detailed reporting about their experiences. Even a small group of reports can be very useful for uncovering patient expectations and presenting a graphic picture of your strengths and opportunities for improvement.
The kinds of mystery shopping assessments DHA professionals can perform are almost limitless. Those requested most include telephone calls, outpatient, inpatient, ER, clinic and competitor visits. In most cases, the mystery shoppers proceed through the entire inquiry, scheduling, registration, treatment and discharge processes. We’ve even gone up to the point of surgery. Occasionally we have requests for observation only visits, “shadowing,” or pairing mystery shoppers as companions to real patients.
Ethnography — Ethnographic studies depend on one or more observations and interviews conducted by DHA consultants. Ethnography is a relatively long-term, labor-intensive process. It requires consent from carefully chosen participants, sufficient …
In the September 2013 issue of the Allegheny Medical Society Bulletin, Dr. Fred Rubin provides a first-hand account of his experience as a patient in the hospital where he works. He recalls the various tests, procedures, diagnosis and care he received in the Emergency Department and during his 14-day hospital stay.
Dr. Rubin describes the frustration of sleep-disrupting procedures and the helplessness he felt as he lost control of his body. In summarizing the “good and the bad” of his time spent as a patient, he concludes that his overall hospitalization was a “terrible experience.”
Although this likely wasn’t what hospital management wanted to hear, Dr. Rubin’s knowledge of the hospital’s policies and procedures — along with his expertise as a physician — put him in the ideal position to suggest changes to improve the patient experience.
I had a similar opportunity when my husband, a physician, needed emergency care last fall. My background as a hospital executive and a medical mystery shopper enabled me to “see” instances worth reporting to management as I sat by my husband’s side during his visit to the hospital’s Emergency Room, his 17-day hospital stay and discharge to home care. Like Dr. Rubin’s account, there were good and not so good experiences.
In the January 2, 2014 Hospital Impact blog, Jason A. Wolf, president of the Beryl Institute suggested that finding the greatest opportunities for excellence and improvement in the patient experience comes back to a willingness to constantly ask questions, try new things and avoid being lured in by promises of “best practices” or prepackaged solutions.
I found Jason’s comments interesting when thinking about why more healthcare organizations don’t try mystery shopping to take their service and patient satisfaction to the next level. Unlike other service industries that routinely use mystery shopping reports to increase customer satisfaction and retention, many healthcare leaders are reluctant to take advantage of this powerful decision-influencing tool. It’s sometimes perceived negatively as a “gotcha” program rather than a way to make factual observations or a way to assess performance against standards.
The mystery shopping report
Mystery shopping reports are produced by individuals who know how to think, speak, and behave like “real” patients. These individuals have fictitious but believable symptoms, complaints or needs. Sometimes a doctor or two is involved in the plan. As ER patients, outpatients and inpatients, or as callers scheduling appointments and making inquiries, the mystery shoppers inconspicuously take notes about their encounters and observations, and turn these notes into a clear and insightful first-hand account of their entire experience. Depending on what the organization wants to know about its operations, the compilation of these individual accounts plus associated questionnaire responses are then turned into detailed reports that:
Price transparency will be one of the top industry issues for 2014 according to recent Modern Healthcare and PwC’s Health Research Institute’s reports.
- Cost conscious employers are making price transparency a factor in negotiations with health plans and providers;
- A little-noticed provision in the Accountable Care Act (ACA) requires all hospital to publish and annually update their standard charges for items and services; and
- Patients, who are being asked to pay more out-of-pocket are demanding more information on healthcare prices.
A National Business Group on Health study found that more than 1 in 5 U.S. employers (22 percent) had plans that required a minimum deductible of $1,250. Also, because of the botched healthcare.gov rollout, the loss of medical insurance by over 6 million people, employers downsizing or moving employees onto the exchanges, many citizens will be required to pay more out-of-pocket for their healthcare. Moreover, according to the Wall Street Journal, “bare bones” plans that were supposed to become obsolete will survive because of a quirk in the ACA law — as long as companies offer at least one plan that complies with the law, they can keep offering ones that don’t!
It’s great that hospital leaders, managers and staff are doing more rounding on patients. No doubt, rounding helps staff understand their patients better and helps patients understand what’s happening to them and why. But rounding doesn’t always identify what patients or their families are thinking and feeling about the staff, systems and procedures they encounter. Things that your staff might consider trivial may actually create distress and dissatisfaction among others.
Over the many years that we’ve been mystery shopping in hospital Emergency and Outpatient Departments, and on the floors as inpatients, we’ve been able to detect certain “little things” that tend to occur frequently and make patients and families feel disrespected, dissatisfied or unimportant. What follows are the most common:
Today’s hospital leaders are devoting significant time and resources developing approaches to better understand the key drivers of the patient experience and create a culture of service excellence. They’ve encouraged and supported patient advisory councils, focus groups, patient experience committees and hourly rounds on patients. Their staff’s are instituting daily “huddles” to keep care teams informed and focused on patient service. They’re analyzing the costs versus the benefits of patient perks such as enhancing the physical environment and ambience, creating tasty meals, adding valet and concierge services, and extending visiting hours.
What many of these leaders are not doing, however, is taking advantage of a powerful tool that affords them an unmatched view of what patients liked and disliked during random investigations of the hospital. That tool is a mystery shopping report — detailed compilations of individual experiences created by various incognito “patients” from the time of registration or admission all the way through to discharge.
Mystery shopping reports are produced by individuals who have received specialized training on how to think, speak, and behave like a patient. These individuals have fictitious but believable symptoms or complaints. Sometimes a doctor or two is involved in the plan.
Today’s patients are armed and potentially dangerous – but not with handguns or grenades. Their weapon is the Hospital Consumer Assessment of Health Providers and Systems, or HCAHPS. And how patients respond to this standardized national survey could be risky to your facility’s bottom line.
When asked to participate in the HCAHPS survey, many patients are telling it like it is – or at least the way they perceive it to be. But perception is a problem with this tool that promises a more consistent and comparable way to measure patient satisfaction. That’s because perception is subjective, and even though participants can respond with only one of four answers — either “always,” “sometimes,” “usually” or “never” — their responses can still be skewed by their perception of how they and their care were handled.
A few weeks ago I had a medical emergency and ended up being a direct admit to the hospital. I arrived at the Emergency Department in the evening and was discharged 26 hours later with a camera in my small intestine. I’m happy to say that all the testing indicates that there is nothing seriously wrong. It’s just some kind of blood vessel malformation that I’ve probably had all my life.
But the experience hit home an important lesson to me: It’s very different being a “real” patient than a “mystery” patient. As a “real” patient I didn’t feel inclined to make notes of any encounters or events. As a result, I can’t remember everything that happened or who I met during the visit; what went through my head as I was processed through registration, triage, testing, admission to the nursing unit, more testing and the inevitable waiting.
Retail and food service organizations already know that mystery shopping is a proven way to ensure customer satisfaction and increase profits. And the same thing is true in healthcare. Whether you are currently pro or con on the subject, or have never given it any thought, we will arm you with the unbiased information you need to make the right decision about mystery shopping for your organization.
Is There a Downside?
Since my firm first started marketing its “mystery shopping” service 22 years ago — first to long-term care facilities and retirement communities and then to hospitals and clinics across the country — we’ve discovered that it often inspires one of two strong reactions: immediate interest or on-the-spot suspicion.
Whether you love or hate the concept, mystery shopping has grown in popularity, and it’s important to understand what it can (and can’t) do for your organization. For example, it’s not a quick-fix way to identify an organization’s sales or customer service woes. Nor is it, as some employees fear, a cleverly covert way for managers to achieve their hidden agenda.