Mystery Patient

On sly, workers rate hospital service
By Liz Kowalczyk, Globe Staff
June 13, 2007

The young woman slipped into a busy primary care waiting room at Beth Israel Deaconess Medical Center, took a chair in the back row, and pretended to read Shape magazine. As patients streamed in, standing in line to speak to a receptionist, she began taking notes on a form concealed in her magazine.

"She was engaged in a very long personal conversation," the woman wrote about one of the receptionists, who was talking to another employee. "At one point the line was several deep, but the person . . . was not helping to check people in."

The note-taker is a mystery shopper, one of a new breed of hospital employees in Boston and nationwide who secretly watch fellow workers to see whether patients are treated courteously and helpfully.

Beth Israel Deaconess began a mystery shopper program two years ago to monitor telephone operators who schedule appointments for patients and later expanded the program to outpatient waiting rooms in November.

Executives credit the shoppers with bringing about vast improvements, especially in telephone etiquette, with instances of poor service becoming far less frequent. Since staff began posing as patients calling to make appointments, the average customer service rating the callers gave telephone appointment specialists, on a 1-to-5 scale, jumped from 2.6 (fair) to 4.8 (excellent).

Read the full story at The Boston Globe

Critique of medical mystery shopping, article and concept:

It is possible that the program BI/Deaconess has put into place has had the effect of improving medical service, which it seems should be the goal of any improvement in patient/provider relations and should be properly measured in terms of patient outcome as well as by patient satisfaction/service ratings. But from this article, there is no way of knowing that. In the Globe story, the medical center's goals for improvement are stated in terms of patient loyalty and competition with other high quality area hospitals (for patients, presumably privately insured patients). The measurements which are meant to bear on these goals are given in terms of customer service ratings (the 5 point scale).

The big threat poor service presents is not simply a reduction in patient satisfaction (i.e., happiness with the courteousy of the receptionist, satisfaction with the speed with which the phone was answered) which may result in patients lost to a better, or at least more pleasant, medical group. The big threat discourteous "front end" medical encounters have is that they can create unnecessary impediments to communication and therefore threaten satisfactory medical outcomes.

A patient who feels he has been subjected to rude or overly distant treatment before ever setting foot in the exam room is primed to interpret later, crucial interactions with the medical practitioner negatively. Such negative priming is a set up for communication failure. Even if this failures occur only on small, local scales in the discourse, those little failures can add up to trigger distrust behaviors in the patient, e.g., witholding information or offering over-explanations of trivial details. They can also cause the provider to feel the patient is being unnecessarily offensive and can make the provider start acting defensive.

Feedback happens, and then you're in a loop. I've seen this as both a patient and a witness to provider/patient interactions. It can get ugly. It can be subtle. But it's always bad. Even in a non-worst case scenario, a patient who has been negatively primed may be unwilling or unable to make the necessary basic connection which facilitates any communicative exchange let alone ones where the purposes are multilayered and complex, like collecting a full and relevant a history as possible or educating a patient on sucessful home care for a newly diagnosed condition. The success of such discourse goals relies on at least a minimal degree of communicative openness of the patient. If your patient shuts off before you start talking, you're going to see that patient again - oh yes. Your diabetic patient is going to show back up with a foot ulcer because while he understood every single word which came out of your mouth about his condition, something was blocking those oh so important supralinguistic cues which would have communicated the gravity and absolute necessity of practices like daily foot exams and proper preventative care of his feet - like not wearing shoes which pinch or otherwise do not fit well.

Now that is a bad outcome.

Asking someone explicitly "how happy were you with the service?" is certainly one way to measure the affect with which that person entered the exam room, but implicit measures like outcome, understanding instructions, perception of physician's openness, are important too. Data from those implicit measures linked with improved "customer service" and higher "customer satisfaction" like scores is what medical providers need to see if they are to be sold on the idea that attending to customer service is anything other than needless, wasteful, and insulting pandering to corporate culture.

I worked in hospitals during the late 80s - mid 90s. I think I was there for what was the beginning of a serious push to consumerize medicine. Such promotions were not received well by the staff at either hospital I worked at. I remember at the first hospital we had "Total Quality" something-or-another workshop sessions with outside patient relations specialists. Except they weren't patient relations specialists or patient relation workshops, they were customer service specialists giving us a customer service workshop. The vocabulary was straight out of a department store employee training program (which was not lost on the medical staff). Many members of the non-clerical nursing staff felt seriously cranky at being told to adopt a "customer is always right" mentality with a patient population. Some of them were outright hostile. "If the patient were always right, we wouldn't need hospitals. They could just diagnose themselves!" one nurse argued to the receptive audience sitting at the smokers' picnic table during a break from the training workshop. Her sentiment was echoed in the workshops as well. We had a week of this training and I recall one day where only half the staff returned after the break.

Although there were some beneficial elements to what we were being sold back then, the "customer service" approach failed to gain a foothold in the hearts and minds of the staff. There was a clear disconnect between what the service specialists running the training knew about patients, health care work and medical culture and the realities of patients, health care work, and medical culture. But there was also the sense that medicine was special, that health care was immune, something separate from mundane concerns like putting your best face on for a patient (essentially all we were being asked to do). What was misssed and what I came to understand as I matured in my job was that patients are like the very worst customers ever. They are having THE WORST DAY, each of them. They've been robbed of some self determination, each of them. Even if it's just to have had their day hijacked by a miserable headcold turning into something bacterial, or to have had their summer vacation plans wrecked by hearing they need to have surgery and they can now chose betwen taking time off to relax or taking time off to be cut into...because the job does not allow time off for both.

Being told I should treat these people like they were the most special person ever, well, in that context it makes sense. I wasn't always great at it, but I thought about how much it sucked to go to sleep at night in a hospital and that usually set me right. But I didn't do it because I felt it was a good idea from a profit optimization perspective (which essentially is what underlies goals like "increased patient loyalty"). I did it because it was the right thing to do from a humanist perspective and because it was the right thing to do if I wanted to do my job right.

Here's how it worked.

Getting into an argument with an argumentative patient is not going to help ANYONE, in fact it's going to slow me down. I will spend time on that and I won't get these orders entered. The patient who was just admitted will not have his blood drawn on the very next phlebotomy round (in 20 minutes) and will have to wait at least another two hours, unless the doctor wants to make it a stat draw. The doctor wants, no NEEDS, some of this bloodwork now. So she writes it for a stat draw. I page phlebotomy, they come and poke him, but meanwhile there are three other labs which had been written and transcribed for a routine draw and which the doctor forgot to add onto the stat draw. Now the patient is going to feel like a pincushion. And probably come out and tell me so. Moreover, the dinner tray will be delayed for this other guy until I am done with the argumentative patient. It will come up very late, he will eat it very late and he will vomit later, and the house officer will be paged because the patient is vomiting...very very late. The patient I let bait me into an argument will have called family from his room and they will have called the desk - not necessarily to complain about the "rude clerk" but to ask if their father "really is going to be discharged tomorrow and if so, when? I need to know when. I can't just wait around again..." The family will be irritable and will irritate the nurse I have to page to speak to them (some of them btw, the other two were in earlier tonight and the nurse already told those two all of this already). Or maybe she is very sweet and nice and isn't irritable but is now running behind. She will subsequently forget to let me know when she hung the antibiotic and I will not be able to time the peak draw after. The secretary whose shift is after mine will have to deal with an angry resident who is looking for that peak level. After being yelled at for the earlier shift's mistake, the secretary will call radiology to schedule a portable X-ray and when she is told it will take several hours, she will get cranky with X-ray.

...And it will just keep on spreading...

And I could have stopped it or at least not participated in it by being more tolerant with this patient who is being inappropriate if you hold people having that bad a day to the same standard of "appropriate" as you do people who aren't.

The general messages and principles of customer service are in fact the ones I found myself employing in good patient interactions - or in setting to right bad patient interactions. Those are things I think of in terms like "I don't have the right to get in the last word" and "It doesn't matter who started it". I learned these things but not from the quality/customer service training, although these messages were right there in the quality/customer service training. Why wasn't I able to pick the message up from the training? Packaging - the total quality training person did not know enough about medical culture to know what language to put it in. And also that I had been indoctrinated into the health care culture as staff. Mom had been a nurse forever. My aunt was a nurse. My boyfriend, fiance, and then husband was a doctor. As someone who had been raised on the medical culture, the idea of applying customer service models to medicine raised my hackles, just on principle. It took me many years and some time as a patient to really fully understand the obstacles a poor attitude can have on patient relations, and the very negative effects poor patient relations can have on people's spirits, and the connections between that and medical outcome.

If obstacles to clear communication can be prevented or reduced, then a drive to improve "customer service" in the medical setting clearly has genuine positive value. But until that value is shown, it will be hard to convince the medical community of the worth of such indirect measures as the third person evaluation of the "front end" service. The medical community has as an easy critique in the fact that the worth of such measures relies on unstated assumptions about what elements of medical interactions are important to the patient/care giver relationship and what are not. I.e., someone eating a donut at a desk (one of the instances of "bad service") is not something which will predispose me to a negative experience or sense of being on the receiving end of a callous medical staff, at least the donut alone certainly won't.

So then what are the right things to measure? Trust, understanding, and outcome would be good places to start. There is overlap in "customer service" and "patient relations", but it is certainly not a full overlap. To perhaps overextend the retail metaphor, there needs to be a good product as well as a smiling clerk who sells it to you. Without attention to the quality of the product, conceding to the push to smile, nod, and wave feels like selling the patient short and selling yourself out.