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Dome - Going undercover on behalf of the patient

April 2011

Going undercover on behalf of the patient

Date: April 6, 2011

Mystery health care shoppers find ways to improve service


Kelly Cavallio
Kelly Cavallio

Waiting 2 hours and 15 minutes for a simple follow-up visit is “entirely too long,” reported Mystery Shopper 45293 after visiting an outpatient clinic at The Johns Hopkins Hospital. “Until the schedule is better managed, the staff should regularly update patients on the expected wait time.”

Meanwhile, Mystery Shopper 45493 heaped praise on Pediatric Surgery: “I was so impressed that I would like to nominate everyone for an Extra Mile Award. Sure, there were a few scuff marks on the floors and the signage could have been a little more direct, visible and clear, but overall, everyone here seemed committed to helping children and they put everyone at ease.”

These observations are among the first evaluations from a mystery shopping study that’s under way at outpatient areas of Hopkins Hospital. Intended to find ways to improve patient satisfaction—a goal shared by leaders across the institution—the program uses health care mystery shoppers, people paid to impersonate patients and their family members, to record the quality of their hospital experiences.

Approved by the American Medical Association, such undercover reporting reveals how clinic staff members and appointment schedulers interact with patients, providing information that is more detailed than Press Ganey’s national patient satisfaction surveys. Kelly Cavallio, administrator of East Baltimore ambulatory services, says the program is an effective way to identify barriers to delivering patient-centered care.

“We need to create a more engaged culture amongst our staff,” she says. “Just because you’re technically good at your work—say your job requires good computer skills—you can’t neglect service. You also have to do a good job of taking care of the patient on the other side of that computer.”

Perception Strategies Inc., a health care mystery shopping company, holds the contract to evaluate the “people skills” of Hopkins outpatient health care providers, clinic staff and telephone schedulers. The program, which runs until 2012, concentrates on such areas as communication, courtesy, professionalism and empathy, as well reporting on wait times, attention to patient privacy and the nature of the physical environment. Supported by Hopkins’ Clinical Practice Association, the initiative is funded by Johns Hopkins Service Excellence and Ambulatory Services.

During the first part of the study, from September 2008 to October 2010, 15 mystery shoppers made 77 clinic visits and 102 telephone calls to set up appointments. The departments they “shopped”  included anesthesiology, dermatology, radiology, medicine, neurology, neurosurgery, obstetrics/gynecology, physical medicine and rehabilitation, ophthalmology, orthopedics, lab services, otolaryngology, pediatrics, surgery and urology.

Courtesy and empathy

While 88 percent of the shoppers were completely, or mostly, satisfied with their in-person encounters, only 62 percent felt that way about making an appointment by telephone.

“One of our goals is getting the phones answered, getting people to answer them pleasantly and also sound as if they care about the patient,” says Becky Zuccarelli, senior director of service excellence for Johns Hopkins Health System. She says while inpatient satisfaction relies largely on patients’ perceptions of individual nurses and support staff, outpatient satisfaction depends on their impressions of the process of obtaining care.

Departments participating in the mystery shopping program were selected because they had received low scores on the Press Ganey surveys. Those evaluations show that although outpatients generally feel well treated by Hopkins’ health care providers, they often find other employees to be dismissive. Many complain about the quality of their phone conversations.

Robert Oakley, clinic manager for dermatology, is already using mystery shopper feedback to reduce the number of telephone transfers that frustrate patients. Along with consolidating departmental phone numbers, he plans to simplify the phone line’s menu options, dedicating one button to cancelling appointments.

“I expected the survey to show that wait times in the waiting room were an issue, but we’ve learned patients are more frustrated with having to call multiple phone lines and not getting the answers they need,” he says. “It reminds you that the patient experience is not just about their time in the clinic, it’s about the phone calls, call backs, the letters in the mail, the transfer of information. It’s making sure we’re all on the same page throughout every aspect of a patient’s visit.”

Based in Indianapolis, Perception Strategies has performed more than 50,000 mystery shops for clients, including such academic medical centers as Baylor and the Cleveland Clinic as well as the Henry Ford and MedStar health care systems. The company hires Baltimoreans ages 25 to 55 who reflect the local demographic profile and possess good writing skills to serve as mystery shoppers.

When making appointments by phone, shoppers use their own names and identify themselves as “self-paying.” For in-person visits, they often play the part of a “silent family member,” accompanying actual patients to observe what kind of treatment they receive.    

Ethical considerations

The Hopkins program observes all guidelines offered by the AMA’s Council on Ethical and Judicial Affairs. A 2008 report on the practice states that physicians have an ethical responsibility to engage in activities that contribute to continual improvements in patient care.

The council recommends that relevant parties be notified that mystery shoppers will visit, that any data gathered not be used for punitive action, that such feedback not serve as the only data for evaluating clinical performance, and that “secret shopper” patients not adversely affect legitimate patients’ access to medical care.

Hopkins went one step further. Not only were all participating clinics informed of the mystery shopping program, but all staff members received instruction about the criteria on which they would be judged—such as whether they smiled and offered to help patients and whether their name badges were visible.

Clinic managers met recently to discuss the mystery shoppers’ first findings and decide how best to bring about desired changes in attitude and behavior.

“Some of the same people will be shopped again to see if anything has improved,” Cavallio says. Meanwhile, she says the program has also helped spur interest in identifying and promoting those behaviors that will most benefit the overall work culture as departments move into the new clinical buildings.

—Linell Smith

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