The physician executive and patient satisfaction.

IN THIS ARTICLE ...

Find out concrete steps you can take to measure and improve patient satisfaction in your health organization by measuring physician communication skills.

Physician executives are facing tough issues in health care. They are challenged to control costs, manage utilization and increase productivity. What about patient satisfaction and patient loyalty?

While physician leaders typically take an active role in many operational initiatives, they often take a very passive approach to managing patient satisfaction, especially when it involves the behavior of physicians.

Patients' satisfaction with their physicians is often ignored unless a "real problem" or several complaints occur. Handling major complaints is important, but that alone is not an improvement initiative that will increase overall patient satisfaction and loyalty.

Striving to improve patient loyalty is a sound business strategy. There is a direct link between fully satisfied patients and:

* Improved health outcomes

There is increasing evidence that patient satisfaction also makes good medicine. Patients who have great confidence in their physician are more apt to adhere to the physician's treatment plan.

* Reduced malpractice 

In a review of plaintiff depositions, one study found that problematic relationship issues were identified in 71 percent of depositions, Other published studies have shown patient complaints to be a predictor of lawsuits.

* Improved physician satisfaction

Patient satisfaction correlates very highly with physician satisfaction. One of the rewards that should not be overlooked is the gratification that comes directly to the physician as a result of having more satisfied patients.

* Increased profitability

Highly satisfied patients often become loyal patients, and loyal patients lead to improved profitability. Be careful not to confuse "repeat" patients with "loyal" patients because there is a huge difference.

"Loyal" patients will go to the same physician even when they have to drive farther and wait longer. The "repeat" patient may change providers as soon as things become inconvenient. It is patient loyalty that leads to improved profitability. There are four reasons for this:

1. Loyal patients talk about how great their physician is. They become responsible for bringing new patients to the physician.

2. Financial statements have no ability to calculate the "lifetime value" of a loyal patient, nor can they calculate the cost of lost business due to a patient changing providers and never returning.

3. Physicians are more efficient with patients they know well.

4. Marketing research shows that it is five times more costly to get a new customer than it is to keep the one you have, and this applies to health care as much as any other industry.

Frederick Reichheld's research in his book The Loyalty Effect demonstrates a strong correlation between customer loyalty and profitability across several industries. In health care, the "customer" is the patient, and the relationship with the physician is the source of loyalty.

People judge their physicians and other health care staff every day. The average patient does not know how to evaluate the true biomedical knowledge and clinical skill of the provider, yet every patient is an absolute expert on how they feel about the way they were treated.

Their subjective feelings become the primary basis for many of the health care choices they make. Loyalty to a provider usually stems from the sense of a relationship where the patient somehow feels special.

Passive role of physicians

If patient loyalty with their physician is truly significant, why is the approach to improving it such a passive one? Why do we have an assumption that any patient who is not angry and complaining must be completely satisfied?

In no other industry are the behaviors of the most critical providers of service to the customer almost completely ignored by management. In health care, there is almost a belief that if a physician hasn't learned through his/her training how to satisfy patients, there is nothing that can be done about it now. The culture of health care is that everyone is so respectful of each physician's "practice style" that no one ever wants to actually comment on style to the physician. Of course, behind the physician's back people talk routinely about each physician's style.

Nurses and office staff recommend certain physicians to their friends and family while warning them to avoid others. Patients talk about physicians to neighbors, family and friends. With great confidence patients tell their stories and let their friends know who to go to and who to avoid.

Everybody talks to everybody about Dr. Smith, with one exception: Nobody actually talks to Dr. Smith, about Dr. Smith Usually the physician leader also has a strong opinion, but rarely says a word.

A passive approach is also taken because there is often a general lack of confidence as to what to do. Conversations with individual physicians about improving patient satisfaction feel awkward and are often avoided.

Solving the problem

The physician leader needs to build a culture of "service excellence" that emphasizes patient satisfaction and loyalty. The starting point is to view the physician interaction with the patient as part of the fundamental operation of health care. This will lead to at least three distinct management actions:

1. Patient satisfaction must become a legitimate leadership agenda item.

2. Meaningful measurement and feedback from the patients' perspective must routinely take place.

3. Efforts need to take place to develop and continually improve physicians' skills in communicating with patients and patients' families.

Many times patient satisfaction is not identified as a leadership initiative simply because leaders aren't sure what to do with it once it shows up on the agenda. The truth is, it can and should be treated as any other leadership initiative.

The topic needs to be discussed and specific goals need to be established. Goals are typically set for items that leaders believe are important. If there are no goals, it is very hard to convince anybody that patient satisfaction and loyalty is a serious topic.

The basic management activities of reward and reprimand need to exist for the topic of patient satisfaction. The topic needs to be on the agenda for discussion as well as celebration of successes and action plans for failures.

It needs to become part of ongoing communications. It also needs to be part of individual performance evaluations. In summary, it needs to be treated just like any other leadership initiative.

Measuring satisfaction

Leaders always attempt to measure the things that are important to them. Patient satisfaction must be measured on an ongoing and meaningful way or it cannot be sustained as a real initiative.

If it is not measured, the entire topic will be treated with polite respect, but no real effort or change of behavior will take place. Without consistent measurement every anecdote can be countered with a different and equally impressive anecdote that says the opposite, and the entire initiative becomes meaningless.

Ideally, patient satisfaction should be measured at the individual physician level and results should be ranked in a large comparative database. Both aspects are critical for the measurement to be meaningful to the physician.

Patient satisfaction measurement that only measures aggregate scores for the whole group and fails to provide specific scores for the individual physicians is not especially helpful. Physicians do not typically hear very many complaints. When patient satisfaction results are reported for a whole group, each physician tends to truly believe that any deficiencies are due to problems with the other physicians.

Equally important is to have patient satisfaction scores compared in the largest possible comparative database. The absence of any comparative data always deceives everybody into thinking everything is great. Patients tend to rate physicians favorably in surveys, even when they are frustrated and plan to look for a new physician.

Vendors who measure patient satisfaction in health care report that physician scores, using a five point Likert scale where "5" is the best score and "1" is the worst, are almost always between "4" and "5". Therefore, any physician score by itself looks great.

Opinions change dramatically when the data say that over 90 percent of all other physicians measured had a better score.

Developing skills

At the heart of patient satisfaction is the interaction with the patient. The physician's communication skills make the difference.

The Bayer Institute for Healthcare Communication points out that communication skills can be learned and improved upon continuously. They should be viewed similarly to learning a procedure.

Yes, individual traits make a difference, and yes, some physicians are more natural communicators than others. At the same time, it is not true to say that nothing can be done and that physicians can't improve. There is no ceiling on communication skills and everyone can improve.

Developing better communication skills requires a new level of understanding, which requires training. Attendance, by itself, at a workshop doesn't accomplish anything. Changing behavior is what makes the difference.

Communication training only improves patient satisfaction if the physician is willing to work hard at establishing new habits, and breaking old habits.

The significant role of the physician executive is to create a culture that expects physicians to seriously work at applying what they learn in workshops. We have all heard the phrase that "you can lead a horse to water, but you can't make him drink.... but you can make sure he is darn thirsty when he gets there!"

It is the physician leader's job to make sure physicians are "darn thirsty" when they attend workshops on communication skills.

The interaction between the physician and patient is a fundamental core element of health care. Leaders must manage this just like any other part of the business. They need to view it as a top priority, set goals, provide measurement and feedback, hold people accountable and follow through with reward and reprimand where needed.

Training and skill development will help, but it must be supported by a genuine leadership emphasis on patient satisfaction and loyalty to be truly effective.

Robert C. Spahr, MD, is senior vice president of quality at Geisinger Health System in Danville, Pa. He can be reached by phone at 717-271-6464 or by e-mail [e-mail] 

Randall L. Hutchinson, MBA, is director of customer service and performance enhancement at Geisinger Health System in Danville, Pa. He can be reached by phone at 570-271-6358 or by e-mail [e-mail]