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    Stephen A. Dickens
    Stephen A. Dickens, JD, M.A.Ed, FACMPE

    Patient satisfaction surveys have been a staple in virtually every healthcare delivery setting for years. Entire corporations have been created to gather and benchmark this data, and astute administrators use the results to negotiate contracts. From a marketing perspective, we know word of mouth can make or break a physician’s office with patients and referral sources. From a risk perspective, a patient who believes his or her physician and staff are interested and compassionate is less likely to pursue litigation in the event of an adverse outcome. 

    What about this new concept of patient experience? What exactly does it mean? How does practice staff help ensure that patients have positive experiences? What are the risks for those practices that fail? 

    Experience vs. satisfaction

    Most patient satisfaction surveys consist of yes or no questions about how well a practice does in superficial areas. They are simply looking for complaints about cleanliness, responsiveness, wait times and staff courtesy. Patient experience surveys go several steps further. 

    While experience surveys gauge how well a practice is doing in some of these same areas, they are focused on a practice’s success in communicating information to the patient. For example, what is the patient’s knowledge about his or her condition and care? 

    Knowledge is the key in this new model. Patient experience surveys ask whether a practice conveys information and how well that is done. Positive patient experience emerges when a patient is engaged with useful knowledge about his or her own condition, which means healthcare professionals must communicate in ways that patients understand. 

    There is much work to be done in this regard, according to a new study from the Department of Health and Human Services that shows that 12% of patients have proficient health literacy. 

    The study shows that only 37% of patients understand their treatment plans yet 80% of physicians believe patients understood their instructions. Half of all patients walk out of the office not knowing what to do, and then half of the information retained is incorrect. 

    Open-ended questions

    To combat low health literacy, consider the Teach-Back Method, which entails asking a patient what he is going to do when he gets home. This method teaches you to ask questions that begin with “how” and “what” so you don’t get yes or no answers. 

    For example, consider the additional information you might get if you ask, “How many times did you miss taking your medications last week/month?” instead of asking “Did you take your medications as directed?” 

    The first question indicates that you expect a patient to be human and miss a few doses, and it signals a deeper interest because you used an open-ended question. To improve communication, try the following: 

    • Use plain language (not medical jargon) and enunciate. It does not matter how smart you are if a patient cannot understand you. 
    • Ensure that written materials are geared to a sixth-grade reading level to be understood by the broadest audience. 
    • Provide a visit summary outlining a medication regime or procedure preparation.

    Perception matters

    We all know physicians and their staff care about their patients. Why else would they do what they do? The problem is that we often give patients the impression we are busy, distracted and/or unprepared, and that perception becomes reality. Consider the following scenarios:

    Scenario 1: A patient makes an appointment because her back hurts, which should be included in the appointment notes. The receptionist might confirm this at check-in, the medical assistant rooms the patient and documents the complaint, a physician then walks in looking at the medical record and asks why the patient is there. The patient assumes the physician is unprepared or that the medical assistant did not communicate her complaint. The patient then repeats the history, which the physician interrupts because he is busy and knows the patient’s history and the reason for the appointment. Now the physician and the patient are frustrated. A better approach would be for the physician to walk in and say, “I see you are here about your back today. Can you tell me what is going on or has changed since my last exam?” This would demonstrate that the staff is competent, the physician is prepared and knows the patient’s history, and the patient still has an opportunity to be heard without repeating known information. Changing the question can change the perception. It takes no extra effort or time.

    Scenario 2: A patient asks a physician for an antibiotic. After conducting an exam and a quick lab test, the physician decides the patient is suffering from a virus and an antibiotic would be ineffective. Instead of explaining this to the patient and getting his buy-in on a different course of treatment, the physician recommends fluids, rest and time to recover. The patient believes the physician did not listen to him because he wasn’t given an antibiotic, and he doesn’t understand the recommendation. This patient does not believe he received good medical care and might decide to seek it elsewhere.

    Unspoken clues

    Body language is a key component to establishing a good rapport with patients. As one doctor told me, most patients don’t care what you say; it is how you say it. Telling a patient her condition is serious can be undermined if your body language conveys disinterest. Eye contact is essential.  

    In landmark research on the effects of nonverbal communication, author Albert Mehrabian, PhD, shows that there are three elements to face-to-face communication: 

    • Words
    • Tone of voice
    • Nonverbal behavior (body language)

    Face-to-face communication is primarily body language (55%), followed by tone of voice (38%) and spoken words (7%), according to Mehrabian’s study.4 He notes that the nonverbal elements indicate feelings and attitude. When the tone of voice and body language are incongruent with the message, people tend to believe the tone and nonverbal instead of the spoken words. Consider the doctor who is distracted for whatever reason, whether it is another patient or a personal reason, who recommends a patient get a consultation from another physician. The physician’s body language and tone of voice might not properly communicate the urgent need for the patient to seek additional care. The risk: A failure-to-diagnose claim can easily be made when the patient delays care and says a physician failed to properly explain the need for an additional appointment.

    It also works the other way. If you are not looking at your patients when you ask how things are going at home, you might miss a glance exchanged between an older couple before they answer the question. That might signal a potential problem that would have prompted you to dig deeper and learn that the patients cannot afford their expensive medications. 

    From a risk perspective, a patient who believes his or her physician and staff are interested and compassionate is less likely to pursue litigation in the event of an adverse outcome.

    Failing to take the time to connect makes some patients feel rushed in the process, according to research that shows 40% of patients say they feel rushed. Furthermore, the average physician interrupts a patient 18 to 23 seconds into a conversation while the patient would have spoken for only two minutes if uninterrupted, according to published studies. Simply sitting down indicates a collaborative relationship. Effective body language can easily be achieved with these adjustments:

    • Arms open
    • Body orientation, physical barriers
    • Leaning forward
    • Head nodding
    • Slow, steady breathing
    • Pausing before responding
    • Eye contact
    • Same level as patient

    If you are using an EHR or a paper chart, let the patient know you want to make a few notes before breaking eye contact. To emphasize you heard a patient, repeat a few keys phrases while typing or writing to help with your charting and to emphasize that you were listening and what the patient said was important. If using an EHR, the patient now sees it as a tool instead of a distraction. 

    The risk of failure

    Activated patients are more compliant and have better outcomes, according to significant evidence. Patients who do not understand the why and why not of care might not buy into a treatment plan and are then labeled noncompliant. Patients who do not understand how to care for themselves due to low health literacy are almost certain to be noncompliant.

    In addition to ensuring better health outcomes and avoiding adverse events, more healthcare professionals are realizing that the focus on value-based care and payment reform will soon come full circle. Consider the Clinician and Group Survey (CG-CAHPS) that was revised in 2015. Practices should take a long hard look at that tool. The Hospital Consumer Assessment of Healthcare Providers and Systems data is readily available to any patient who can navigate the Internet. If your data was published today, what would it say? Any practice still conducting satisfaction surveys should be transitioning to measuring patient experience.

    Bringing it all together

    As you seek to achieve a positive experience, remember it is all about patient activation. It is not only what you say but how you say it. It is the questions you ask about what is going on with a patient and his or her understanding of the condition and care received. 

    The benefits of patient understanding not only influence outcomes and experience surveys, they create positive marketing and can significantly reduce calls to your office. The time you spend communicating may well be paid back in the time your staff spends on the phone conveying clarification from physicians and returning patient calls.

    Your patients are also going through healthcare reform. They are being told they should have access to information and expect better customer service. As they pay more for their healthcare, it is not an unreasonable expectation. Now is the time to engage with them differently so you are prepared for the day patient experience influences your bottom line. 

    Stephen A. Dickens

    Written By

    Stephen A. Dickens, JD, M.A.Ed, FACMPE

    Stephen A. Dickens is an attorney and vice president of medical practice services at SVMIC. In this role, he advises physicians and their staff on organizational issues, including governance, operations, strategic planning, leadership, patient experience and human resources. He is a published author and frequent speaker at state and national conferences on these topics. Before joining SVMIC in 2008, he worked with physicians in various roles, including 15 years in medical practice, hospital and home care executive positions. 

    Dickens is a past chair of MGMA and was the first solo chair of MGMA-ACMPE. He is a past president of the MGMA Financial Management Society, Tennessee MGMA and Tennessee Association for Home Care. He is a certified medical practice executive and a Fellow in the American College of Medical Practice Executives. In addition, he has previously earned Fellowship in the American College of Healthcare Executives and certification as a home and hospice care executive by the National Association for Home Care. 

    He is the 2015 recipient of the Martha Johnson Distinguished Service Award from the Tennessee Medical Group Management Association, honoring his contributions to the organization and the medical practice profession. He was named Tennessee’s Home Care Administrator of the Year and received the President’s Award for service to the industry from the Tennessee Association for Home Care.

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