At your service: transforming health care delivery.

It's been nearly 15 years since I graduated from medical school, young and enthusiastic about an industry in which some of the brightest, intuitive and hardworking individuals made their careers. I subsequently returned to business school, with the hope of applying some business acumen to health care, and with the vision to help lead a flourishing industry.

Now that I have worked in the health care delivery industry for many years--viewing it through both a clinical and business lens--I have been consistently surprised with a single notion: the health care delivery industry does not function as a service industry at all. In fact, in many respects, health care has not applied many principles that other industries, service or otherwise, have used to improve their performance.

Tunnel vision on quality

Historically, health care organizations relied on traditions of quality performance as their primary differentiating strategy in the marketplace. At large conferences comprised of physicians from numerous organizations, when asked what differentiates their organization from others, the routine response is "our organization is of higher quality than all others."

What the health care delivery industry has yet to see is that clinical quality alone is not a sufficient differentiator. Despite the fact that our society is changing to one of enhanced consumerism, intolerance for poor service and impatience, many organizations continue to fall back on "quality" as their distinguishing feature.

As a result of health care's historical lack of focus on the service elements of its operations, health care delivery is in fact a service industry that doesn't act like one. When you consider the impeccable service offered by the Ritz Carlton, by Southwest Airlines or by premium restaurants here in Massachusetts and elsewhere, the immaturity of health care is readily apparent by the real-time experiences patients suffer every day:

* Waiting six hours to be seen in emergency rooms

* Waiting nine months to schedule a physical with a primary care physician, even though a patient may have barely utilized any services that year

* Playing phone tag incessantly with the doctor's office to try to get through to schedule an appointment or seek advice

* Waiting in queue in waiting rooms, then in exam rooms and then again in the lab or pharmacy requiring patients to take a whole day off from work just to spend 15-20 minutes with the doctor

* Receiving test results weeks after they are complete, or never at all

* Being treated by health care staff as if you are one on a long list to be seen that day, rather than recognized as a customer to be treated with utmost courtesy, respect and admiration

The need for change

When Fallon Clinic in Worcester, Mass., conducted market research and focus groups with health care consumers and asked patients what they wanted from their health care providers, the respondents rarely mentioned quality.

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Instead, nearly 100 percent of all focus group participants highlighted improved customer service as the key opportunity for improvement among most providers. When specifically asked about omission of a focus on quality, patients responded by saying: "Doctors have gone to medical school. That requires hard work and dedication. We presume most doctors will offer high quality care."

This is not an unexpected response when you consider that quality is also assumed in other service industries. For example, is a traveler's concern about arriving, safely at a destination the major factor in a choice between US Airways, Southwest Airlines or American Airlines?

It is clear from a service perspective that health care is in great need of transformation. As physicians and leaders of the health care industry, we have been remiss in supplementing excellence in clinical quality with what consumers want: service quality. To put it another way, patients expect that doctors will care for them, but they want doctors and their staff to care about them.

Some physician groups have recognized that service orientation is important to patients, and is an essential element of success. One notable example is the emergence of concierge practices, groups that offer same-day access for appointments, 24-hour on-call coverage for emergencies, inviting environments and house calls, all for a supplemental fee to doctors for providing these services. The creation of such practices implies that good service in health care must come at a price. This is definitely not so.

Beyond the notion of service orientation, health care must transform in other ways, applying the business principles and techniques long proven and used by other non-health care companies.

For example, many physicians do not use or plan to use modern technologies, such as electronic medical records. That's surprising when you consider the EMRs improve efficiency, communication and safety. Likewise, many of the delays and service problems in health care can be addressed and fixed through sophisticated process redesign. Most other industries have done it, why not health care?

Fallon Clinic's transformation

Fallon Clinic embarked on a path of transformation to right some of these service deficiencies, namely to transition our practice into a "gold standard" of health care delivery. Although steeped in a rich quality tradition and nationally recognized for excellence in clinical quality, our organization realized that a tunnel vision focus on quality is not sufficient to achieve the gold standard.

Employees at Fallon Clinic scrutinized every element of its operational procedure and contractual relationships, and embarked on a strategic transformation. Some of the key elements include:

Accepting multiple insurers

For 25 years, Fallon Clinic was nearly exclusive with Fallon Community Health Plan (FCHP), with the exceptions of some contracts with indemnity insurers, preferred provider organization (PPO) networks and CIGNA Healthcare. Fallon Clinic and FCHP are strong partners; however, this exclusivity limited patient satisfaction for both organizations.

At the clinic, this led to discontinuity of care, where patients were forced to break physician relationships as a result of insurance changes through their employer. Given the patient and physician dissatisfaction associated with these broken relationships, Fallon entered the first phase of the group's strategic transformation by accepting multiple insurers.

Fallon physicians now see patients with multiple forms of insurance including Blue Cross Blue Shield of Massachusetts, Harvard Pilgrim Health Care, FCHP, CIGNA, Private Health Care Systems and others.

Fallon Clinic received strong feedback from patients that contracting with other insurers was long overdue. Over the course of a four-month period, nearly 3,800 Blue Cross Blue Shield patients joined Fallon Clinic, either as first-time patients or as patients returning to their former physicians.

Focus on service

What patients wanted most from their doctors was to be treated as a customer, i.e. to be listened to, respected and treated as they would be treated at good hotels or restaurants. With an understanding that the patient comes first, Fallon began:

* Asking our patients what they want: Fallon revised its patient satisfaction survey process and is now sending out weekly surveys to its patients to understand where the organization can make improvements.

* A customer advisory board was also formed, comprised of health care consumers who will help direct the practice toward those areas in greatest need of change.

* Fallon Clinic is in the process of implementing a training program that mirrors those conducted at Disney and the Ritz Carlton.

* Fallon is recruiting high-quality doctors and staff who are extremely service oriented.

Process re-engineering

Through its focus groups, Fallon learned that correcting appointment delays and telephone delays ran a close second when patients were asked what they wanted from health care. The common misperception among patients is that physician offices are unable to improve access to care because of inadequate staff or too many patients.

Alternatively, I would propose that the primary reasons for inability to improve access are process inefficiencies. A business leader could spend years reviewing thousands of cases of companies that improved throughput and access delays by re-engineering processes. Even the leaders of the Ritz Carlton attest that process improvements are the key to their success.

Fallon is working to re-engineer several processes to reduce wait time, answer phone calls quickly with hold times of less than 60 seconds, and develop a simplified scheduling process that includes treating some basic illnesses at home. Many Fallon Clinic primary care physicians can now see patients for routine physicals within 14 days, some even the same day.

Use of modern technology

Given the use of technology in most other industries, the over-whelming absence of such technologies in health care delivery is remarkable. Fallon Clinic recognizes that the use of cutting-edge technology is critical to process improvement, service enhancement and patient safety.

Over the next two years, the organization will invest in the following technologies:

* Upgraded electronic medical records

* Full scale telephone system and voicemail upgrades

* Voice recognition transcription and switchboard services

* Film-less digital radiology allowing instantaneous X-ray image transmission to distant sites

* Web enhancement including "Web visits" for patients who prefer to communicate with their MDs over the Internet instead of through personal visits or the telephone

Fallon's goal is to be on the leading edge of both patient care and customer service.

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Imagine a world where: You awake in the morning, realize you want a physical exam, log on to the Internet and book your appointment, online, with your doctor, for later that same day. You arrive at your doctor's office and it is warm and inviting, and all staff greet you as you would be greeted when arriving at the best hotels.

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You wait in a waiting room that is as comfortable and inviting as your living room, has recent magazines. Your total visit to the doctor's office is less than one hour, of which more half of the time is spent with practitioners. Your doctor's office staff uses modern technology and when you leave the practice and arrive at your pharmacy, your prescription is filled and waiting for you.

By Craig E. Samitt, MD, MBA 

Craig Samitt is chief operating officer at Fallon Clinic in Worcester, Mass. He can be reached at [e-mail]

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