Patient Surveys Guide Competitive Strategies
Asking customers what they need is one of the best ways of retaining their business, in the experience of Frank J. Lexa, MD, MBA. Lexa is clinical professor of radiology, University of Pennsylvania Medical Center, Philadelphia; professor and Asia regional manager of The Global Consulting Practicum and adjunct professor, department of marketing, The Wharton School, Philadelphia; and adjunct professor of biotechnology, Instituto de Empresa, Madrid, Spain. 
Frank J. Lexa, MD, MBA He presented Service and Quality Methodologies: How to Find Out What Your Patients Really Want at the 23rd Annual Economics of Diagnostic Imaging 2008: National Symposium in Arlington, Va, on October 25. There is, he says, no other $2 trillion industry on earth that exhibits the level of stakeholder dissatisfaction seen for health care today. Part of the problem, he adds, is that there are so many stakeholders, several with interests and incentives leading them in different directions. The customers of imaging facilities, for example, include nearly everyone, at some point: hospital executives, joint-venture partners, private and public payors, regulators, quality/service aggregators, and referring physicians and their office personnel—in addition to patients and their significant others, friends, and relatives. A customer, Lexa says, must be defined not only as the entity that decides to purchase medical services, but also as the individuals and organizations responsible for influencing purchasing decisions, designing and entering contracts, regulating businesses, and affecting how brands are perceived by any of the other customers. Quality and service will be seen differently by these groups, as well as by those within them. For this reason, quality and service in health care need not only closer attention, but better definition. Both can begin with an internal survey of patients’ service/quality opinions and concerns. Why Surveys Are Needed The forces driving health care providers to scrutinize their quality and service levels, Lexa says, are led by unsustainable economic pressures combined with both local and national increases in the intensity of competition among providers. Other drivers are concern for patient safety, escalating scrutiny of medical practices by both private-sector organizations and government agencies, and the sometimes profound effects of medical errors on individuals. In addition, the reports on quality (including the influential To Err Is Human¹) that have been issued by the Institute of Medicine over the past decade have served to inspire quality initiatives in the public and private sectors. That book’s 1999 publication, Lexa notes, came a full 30 years after the public’s respect for the medical profession began to decline from its 1969 peak. Today’s physician is far less likely to practice medicine unquestioned, and today’s model of medical-service delivery has changed just as much. By 2010, there may be 29 million health savings accounts in use, as part of what Lexa describes as health care’s retail revolution. This change will put as much as $600 billion of premiums under consumers’ control, instead of being spent at the discretion of employers or government programs. With individuals making more of the spending decisions, a proliferation of providers stressing convenience can be expected, with MinuteClinic™ and similar in-store, retail health services being examples of this shift. For this reason, conducting surveys to determine what patients think of a practice, and what they need and expect from it, has become more important than ever. As Lexa points out, the providers and recipients of care see the process quite differently. Of course, the customer is not always right, but knowing which changes the practice should make to improve its competitive abilities depends on understanding the customer’s point of view. A survey can be among the best ways to elicit that viewpoint. Even when the customers are wrong, surveying them to find out what they want will provide the practice with high-quality market research at a relatively low cost. In addition, the feedback that the survey process provides for the practice’s managers lets them know where employees are doing well and where changes are needed. Designing the Survey Lexa reminds practices that it is important to know not only what questions to ask, but why to ask them. Making a survey longer by asking questions that will not lead to any action can defeat the purpose of the project and discourage patient participation. The primary activity categories to consider in writing survey questions are scheduling and other preprocedural contact, whether the patient and family would describe the imaging experience as satisfying, whether the exam was performed on time, whether the facility was clean and convenient, whether the patient was treated considerately and respectfully, whether reports were available to the referring physician on time for follow-up care (from the patient’s perspective), and whether service exceeded traditional expectations. Surveys should be designed to find out what service and quality mean to patients, with the understanding that the act of asking for a patient’s opinion will, in itself, often change that patient’s perception of the practice. The practice should use the survey both to capture data showing how well it is performing now and to decide what steps it needs to take to ensure continued success or improvement. Of course, it is necessary to reduce biases accidentally introduced through the survey process, but there are many areas where bias must simply be considered in evaluating results because it cannot be eliminated. Biases can be generated by the choice of patients to survey, by who the surveyor is, by the response rate, and by the wording of both questions and response choices. One way of preventing too much bias in who responds is to ensure that the survey can be answered in a short time. Keeping it less than 5 minutes long, for example, will make it less likely that only highly motivated (perhaps disgruntled) patients would be willing to complete it. Lexa also recommends using open-ended questions in order to obtain useful advice that a more rigid type of survey might not be able to gain. Obtain legal advice first, he says, but consider offering small rewards as incentives for survey participation. Patients should also be given the chance to indicate that they wish to be contacted for follow-up questions (or to resolve problems). Survey language is important, with a 10th-grade reading level being ideal. Questions should be unambiguous and, if translated for a multilingual patient population, should be carefully reviewed by native speakers to ensure accuracy. Demographic questions should be minimized, and Lexa recommends avoiding any response choices allowing the patient to claim that he or she doesn’t know the answer or has no preference. It can be easier for the patient to complete the survey (and for the practice to construct it) if questions are asked in chronological order. For example, the questions might begin with the period before arrival at the facility and then proceed through arrival, receptionist acknowledgment, front-desk intake, technologist contact, changing clothes before the study, the imaging session, discharge, and follow-up contact. While it is best to conduct surveys in person immediately after imaging, before the patient leaves the facility, other methods can be practical. These include paper questionnaires (either given to patients to take home or mailed to them), Web-based questionnaires, and surveys conducted by telephone. Using the Results If a practice is bothering to perform a survey, Lexa says, it is important to pay attention to its findings, even if they are sometimes unpleasant. Compliments are good reinforcement for high levels of performance, but complaints are more valuable because they lead to important changes. Correct whatever can be changed based on the survey’s findings, remembering that patients who are dissatisfied can harm the practice. Worse, an angry patient (especially one who is active online) can damage the practice’s reputation to a degree that was unthinkable before widespread Internet use. Patients who contact attorneys because they are unhappy are similarly damaging, so it is simply good policy, when the survey identifies angry patients, to hear their complaints and attempt to correct their problems whenever feasible. Because an imaging center has so many different types of patients, it can be helpful to categorize survey responses by patient category, thereby finding characteristics that each group’s members might have in common. For example, the worried well who seek screening procedures might be more or less appreciative of a pleasant waiting area than regular patients are; this will not be apparent without categorization of survey responses. Lexa suggests other possible categories: first-time versus frequently seen patients, physically independent versus dependent patients, those whose care is directed by guardians versus those who make their own care decisions, active versus passive patients, and those who are well informed versus those who know little about their conditions or options. In summary, Lexa says, the most important steps in pursuing a service/quality initiative based on a patient survey are: first, to determine the goals of the project; second, to decide where the practice’s responsibilities for (and control of) service and quality variables begin and end; third, to plan the practice’s responses to various possible survey findings, and to designate responsibility for those actions; and, fourth, to decide precisely what to measure using the survey. At that point, the survey can be created, administered, and evaluated with the knowledge that it will be of high value in securing the practice’s competitive position.
Frank J. Lexa, MD, MBA He presented Service and Quality Methodologies: How to Find Out What Your Patients Really Want at the 23rd Annual Economics of Diagnostic Imaging 2008: National Symposium in Arlington, Va, on October 25. There is, he says, no other $2 trillion industry on earth that exhibits the level of stakeholder dissatisfaction seen for health care today. Part of the problem, he adds, is that there are so many stakeholders, several with interests and incentives leading them in different directions. The customers of imaging facilities, for example, include nearly everyone, at some point: hospital executives, joint-venture partners, private and public payors, regulators, quality/service aggregators, and referring physicians and their office personnel—in addition to patients and their significant others, friends, and relatives. A customer, Lexa says, must be defined not only as the entity that decides to purchase medical services, but also as the individuals and organizations responsible for influencing purchasing decisions, designing and entering contracts, regulating businesses, and affecting how brands are perceived by any of the other customers. Quality and service will be seen differently by these groups, as well as by those within them. For this reason, quality and service in health care need not only closer attention, but better definition. Both can begin with an internal survey of patients’ service/quality opinions and concerns. Why Surveys Are Needed The forces driving health care providers to scrutinize their quality and service levels, Lexa says, are led by unsustainable economic pressures combined with both local and national increases in the intensity of competition among providers. Other drivers are concern for patient safety, escalating scrutiny of medical practices by both private-sector organizations and government agencies, and the sometimes profound effects of medical errors on individuals. In addition, the reports on quality (including the influential To Err Is Human¹) that have been issued by the Institute of Medicine over the past decade have served to inspire quality initiatives in the public and private sectors. That book’s 1999 publication, Lexa notes, came a full 30 years after the public’s respect for the medical profession began to decline from its 1969 peak. Today’s physician is far less likely to practice medicine unquestioned, and today’s model of medical-service delivery has changed just as much. By 2010, there may be 29 million health savings accounts in use, as part of what Lexa describes as health care’s retail revolution. This change will put as much as $600 billion of premiums under consumers’ control, instead of being spent at the discretion of employers or government programs. With individuals making more of the spending decisions, a proliferation of providers stressing convenience can be expected, with MinuteClinic™ and similar in-store, retail health services being examples of this shift. For this reason, conducting surveys to determine what patients think of a practice, and what they need and expect from it, has become more important than ever. As Lexa points out, the providers and recipients of care see the process quite differently. Of course, the customer is not always right, but knowing which changes the practice should make to improve its competitive abilities depends on understanding the customer’s point of view. A survey can be among the best ways to elicit that viewpoint. Even when the customers are wrong, surveying them to find out what they want will provide the practice with high-quality market research at a relatively low cost. In addition, the feedback that the survey process provides for the practice’s managers lets them know where employees are doing well and where changes are needed. Designing the Survey Lexa reminds practices that it is important to know not only what questions to ask, but why to ask them. Making a survey longer by asking questions that will not lead to any action can defeat the purpose of the project and discourage patient participation. The primary activity categories to consider in writing survey questions are scheduling and other preprocedural contact, whether the patient and family would describe the imaging experience as satisfying, whether the exam was performed on time, whether the facility was clean and convenient, whether the patient was treated considerately and respectfully, whether reports were available to the referring physician on time for follow-up care (from the patient’s perspective), and whether service exceeded traditional expectations. Surveys should be designed to find out what service and quality mean to patients, with the understanding that the act of asking for a patient’s opinion will, in itself, often change that patient’s perception of the practice. The practice should use the survey both to capture data showing how well it is performing now and to decide what steps it needs to take to ensure continued success or improvement. Of course, it is necessary to reduce biases accidentally introduced through the survey process, but there are many areas where bias must simply be considered in evaluating results because it cannot be eliminated. Biases can be generated by the choice of patients to survey, by who the surveyor is, by the response rate, and by the wording of both questions and response choices. One way of preventing too much bias in who responds is to ensure that the survey can be answered in a short time. Keeping it less than 5 minutes long, for example, will make it less likely that only highly motivated (perhaps disgruntled) patients would be willing to complete it. Lexa also recommends using open-ended questions in order to obtain useful advice that a more rigid type of survey might not be able to gain. Obtain legal advice first, he says, but consider offering small rewards as incentives for survey participation. Patients should also be given the chance to indicate that they wish to be contacted for follow-up questions (or to resolve problems). Survey language is important, with a 10th-grade reading level being ideal. Questions should be unambiguous and, if translated for a multilingual patient population, should be carefully reviewed by native speakers to ensure accuracy. Demographic questions should be minimized, and Lexa recommends avoiding any response choices allowing the patient to claim that he or she doesn’t know the answer or has no preference. It can be easier for the patient to complete the survey (and for the practice to construct it) if questions are asked in chronological order. For example, the questions might begin with the period before arrival at the facility and then proceed through arrival, receptionist acknowledgment, front-desk intake, technologist contact, changing clothes before the study, the imaging session, discharge, and follow-up contact. While it is best to conduct surveys in person immediately after imaging, before the patient leaves the facility, other methods can be practical. These include paper questionnaires (either given to patients to take home or mailed to them), Web-based questionnaires, and surveys conducted by telephone. Using the Results If a practice is bothering to perform a survey, Lexa says, it is important to pay attention to its findings, even if they are sometimes unpleasant. Compliments are good reinforcement for high levels of performance, but complaints are more valuable because they lead to important changes. Correct whatever can be changed based on the survey’s findings, remembering that patients who are dissatisfied can harm the practice. Worse, an angry patient (especially one who is active online) can damage the practice’s reputation to a degree that was unthinkable before widespread Internet use. Patients who contact attorneys because they are unhappy are similarly damaging, so it is simply good policy, when the survey identifies angry patients, to hear their complaints and attempt to correct their problems whenever feasible. Because an imaging center has so many different types of patients, it can be helpful to categorize survey responses by patient category, thereby finding characteristics that each group’s members might have in common. For example, the worried well who seek screening procedures might be more or less appreciative of a pleasant waiting area than regular patients are; this will not be apparent without categorization of survey responses. Lexa suggests other possible categories: first-time versus frequently seen patients, physically independent versus dependent patients, those whose care is directed by guardians versus those who make their own care decisions, active versus passive patients, and those who are well informed versus those who know little about their conditions or options. In summary, Lexa says, the most important steps in pursuing a service/quality initiative based on a patient survey are: first, to determine the goals of the project; second, to decide where the practice’s responsibilities for (and control of) service and quality variables begin and end; third, to plan the practice’s responses to various possible survey findings, and to designate responsibility for those actions; and, fourth, to decide precisely what to measure using the survey. At that point, the survey can be created, administered, and evaluated with the knowledge that it will be of high value in securing the practice’s competitive position.