Janice Rosenberg

An unexpected mystery shopper helped Bill Edsel gain important insights into Pinehurst Surgical, the 36-surgeon practice in Pinehurst, N.C., where he’s the CEO. Edsel’s wife had a friend whose numerous health problems caused her to visit various members of the practice. 

“Every time she’d come in, [my wife’s friend] would tell [her] she had to wait, didn’t know how long it would be before the doctor saw her, and [then] my wife would tell me,” Edsel recalls. “I talked to the woman and told her to look at the environment and the efficiency of the staff and to report to me. She provided feedback on the doctors and the employees.” 

Edsel came to realize that his patients would be less troubled by waiting if they had more information. With input from staff and physicians, he developed a waiting-room sign that read: “We appreciate your visit with us. If you have waited 20 minutes past your scheduled appointment time, please ask the receptionist to check on your appointment. It’s all about your health, and we want you well.” 

Now Edsel’s already excellent front-desk staff has another tool on hand for smoothing their interactions with patients. 

Any physician who has stopped to think about it recognizes the undeniable importance of a top-flight front-desk staff. Known not so long ago as “the girls,” today these groups of women and men serve as physicians’ primary link to their patients. If they are well-trained and highly professional, they work hard to keep both patients and doctors happy and satisfied. 

The first front-desk staffer who greets a new patient can have a real influence on how that patient views the entire office visit. 

“Front-desk people are the first and last voices patients encounter. They are critical to the practice,” says Ken Hertz, a senior consultant with the Medical Group Management Association (MGMA). “Physicians should call their own main number once in a while to see what their practices sound like.” 

At Northern Rockies Orthopaedics, a five-physician practice in Missoula, Mont., excellent service begins with a patient’s first phone call. When making an appointment, front-desk staff members obtain as much information as possible, including patient demographics and insurance details. Staff members work hard to best ensure a patient is prepared for the visit. They check whether a physician referral is necessary for the appointment, find out whether the patient has had an X-ray or MRI when applicable, and determine how to gain access to pertinent patient records. 

“It makes a huge difference, and it’s worth the time it takes to do it,” says Shawna Brownlee, a checkout clerk with Northern Rockies. “We fill out a form with the billing information and send that to a person in the office who does a benefits check ahead of time. It’s all entered into the [EMR] system. So as a checkout person, I can see if the patient has a deductible or copay and ask for it.” 

Service at Town and Country Pediatrics, a 16-physician practice with three offices in Chicago, also begins before patients show up. Receptionists make an effort to arrive at the office early to prepare the day’s charts and print out the “superbills” the group uses for that morning’s appointments. 

A designated “greeter” meets patients as they come through the front door. She verifies the patient’s appointment, makes sure the patient’s information on file is 
correct, and collects any copays. 

“We ask people to come in 10 minutes ahead of their appointments to help keep the doctors running on time,” says Cecilia Navarro, Town and Country front-desk supervisor. “When they ask why, we tell them it’s to go over the information on their charts, but it’s also to allow extra time in case they get caught in traffic or have difficulty parking.” 

Staying on schedule can be difficult for physicians in busy practices. Addressing long waits is another of the front-desk staff’s many duties. At Pinehurst Surgical, patients who have waited 20 minutes beyond their scheduled appointment time are instructed to step up to the front desk. 


“The instructions for our check-in staff are to call the nurses station at the different specialties and ask how much longer it will be so that they can tell the patient,” says Pinehurst’s second-floor supervisor, Terry Smith. “If a doctor is behind, I just apologize profusely. Some patients you can’t please, but we bend over backward to do it.” 

The front-desk staff at Town and Country Pediatrics works hard to keep physicians on schedule. If a doctor knows she’ll need more than the usual 15 minutes for an appointment, extra time can be scheduled in advance. Patients typically wait no longer than 15 minutes. If they have been waiting longer, they are given the option 
of rescheduling. 

At Northern Rockies Orthopaedics, some physicians run very close to schedule while others tend to lag behind, says Brownlee. She suggests that patients call ahead to determine what their wait time may be. If they have been waiting in the office for a while, she takes their cell phone numbers and suggests they go out and run some errands. 

“We try to explain to the patients that part of the reason the doctors may be behind is that they spend a lot of time with patients, giving them the attention they need,” Brownlee says. “And once a patient has been back for a second visit, he remembers that.” 

Of course, doctors aren’t the only ones who can hold up a day’s schedule. If a patient fails to show up for an appointment at Pinehurst, the staff sends an e-mail to the doctor, who must decide what to do. Staff may be instructed to call the patient or send a letter to offer an opportunity to reschedule. 

Town and Country front-desk workers place reminder calls to patients the day before their appointments and save date-stamped call sheets for six weeks as proof the calls have been made. No-shows are charged $50. This policy has cut down on last-minute cancellations. 

Patients also require thoughtful handling at checkout. At Pinehurst, signs posted in the office explain that patients need to submit copays at the time of service. Nevertheless, patients often complain about being asked for money. 

“When patients check out, they’ve just seen the doctor and may have received bad news,” says Angela Armstrong, a checkout clerk at Pinehurst. “You need to take a little more time and show compassion. Or if a patient is very disgruntled about the care he’s received, you offer a chance to talk to the manager or the doctor. You don’t want people to walk away unhappy.” 

It’s not enough just to hand a patient a checkout sheet and say, “You owe me $50,” agrees Tammy Clark, another Pinehurst checkout clerk who keeps a constant smile on her face while explaining insurance copays to patients. 

Choosing appropriate employees to ask patients for money and training them to do it properly makes a difference, says Jefferson Kilpatrick, a facial plastic surgeon at Pinehurst. He says the person who collects copays at his practice does “a phenomenal job.” 

“Part of it is she’s not afraid to ask for the money,” Kilpatrick explains. “Another person may not feel as comfortable … Maybe a person who doesn’t feel like asking for money is better as a greeter.” 

In general, the best front-desk workers possess excellent communications skills. Listening attentively can make all the difference in how patients feel when they leave the office, says Nil Tunca, Town and Country’s practice administrator. 

“When they want to talk, most patients want me to listen without interrupting and let them vent,” Tunca says. “At the end, they feel better for getting it out, and they usually apologize for taking my time. I take notes on dates and issues and ask them how I can resolve the problem. I always tell them I will get back to them, and I do. That’s usually very satisfactory.” 


Not that long, ago physicians managed their own front-desk staff. But today with practice managers and administrators more frequently taking on that responsibility, doctors can focus on what they do best - treating patients. 

“A great front-desk staff communicates with our patients to satisfy their needs and solve their problems on a day-to-day basis,” says Howard Rice, a pediatrician and the president of Town and Country Pediatrics. “They sometimes are shock absorbers or play the role of an educator, translator, and psychologist to the needs of patients.” 

But where do those great people come from? When hiring people, Robin Monogue, Northern Rockies Orthopaedics’ office administrator, wants to be sure they will fit in with the established front-desk staff team. People who come for second interviews spend a minimum of two hours test-driving the positions they’re applying for. This helps them understand exactly what the jobs entail and gives staff members a chance to look them over. 

“Then I poll the staff, and we as a group decide on who will work best in our office,” Monogue says. “That shows the staff that I don’t just hire someone and put her in place. I want their input, I want them to be happy, and I want a personality that works with all of them. They have a part in the hiring and don’t feel that I’ve forced someone down 
their throats.” 

Continual training can keep front-desk workers at the top of their game. As a result of cross-training at Northern Rockies Orthopaedics, if one staff member is away, there is always another who knows her job and can step into her place. This leads to a strong sense of teamwork. 

Monthly staff meetings strengthen that sense of togetherness. At Northern Rockies, these meetings may involve training in new procedures or offering individuals a chance to communicate about current and ongoing problems. Monogue runs two seminars for improving office morale with the humorous titles, “Give Them the Pickle” and “Fish.” Both focus on customer service and how to get along with other staff members who may have difficult personalities. 

Monogue, who says the doctors in the practice bring a sense of fun to the workplace, affirms that physicians also can help contribute to staff morale. When a new deli opened in town, one physician suggested ordering lunch for the staff so everyone could try it out. 

“The staff has learned not to be afraid to approach a doctor when a problem comes up in their clinic, and the doctors are very helpful in return,” Monogue says. “They’re approachable, and, because of that, problems get solved rapidly.” 

Terry Smith says ongoing training at Pinehurst Surgical helps the daily schedule run smoothly and gives staff members the self-confidence of knowing they are good at what they do. Smith and Pinehurst’s other floor supervisor, Carolyn Ussery, meet weekly with their management team to listen to concerns, talk about what’s coming up, and ask how they can better help the staff. 

“It’s a communication tool; it may take just five minutes to learn what we can do to help each other,” says Ussery, referring to her relationship with Smith. “We also talk daily by phone, e-mail, or face-to-face. We have two floors at our office, and this keeps them in touch.” 

Pinehurst’s 18 check-in clerks work well together as a unit. Smith and Ussery agree that having tough skin, speaking one’s mind, and remembering to let go of small 
hurts makes that possible. 

“When you spend eight hours a day together, you’re like a family, and you know how families are,” says Armstrong, jokingly. “Sometimes they don’t get along. But we work it out, talk it out, and get back to business because that’s what it’s about: keeping the business going.” 

Janice Rosenberg has been a Chicago-based health care and business writer for more than 15 years. Her work has appeared in local and national publications, including Physician’s Financial News and the Chicago Tribune. She holds a master’s degree in library science. 

This article originally appeared in the March 2007 issue of Physicians Practice. 


Articles

Front-desk staff know more than you think about running a successful practice. All you have to do is ask. So we did.

Operations: Tales From the Front


An unexpected mystery shopper helped Bill Edsel gain important insights into Pinehurst Surgical, the 36-surgeon practice in Pinehurst, N.C., where he’s the CEO. Edsel’s wife had a friend whose numerous health problems caused her to visit various members of the practice. 

A designated “greeter” meets patients as they come through the front door. She verifies the patient’s appointment, makes sure the patient’s information on file is correct, and collects any copays. 

Monthly staff meetings strengthen that sense of togetherness. At Northern Rockies, these meetings may involve training in new procedures or offering individuals a chance to communicate about current and ongoing problems. Monogue runs two seminars for improving office morale with the humorous titles, “Give Them the Pickle” and “Fish.” Both focus on customer service and how to get along with other staff members who may have difficult personalities.

has been a Chicago-based health care and business writer for more than 15 years. Her work has appeared in local and national publications, including

. She holds a master’s degree in library science. 


This article originally appeared in the March 2007 issue of

Lakeview Family Health Care in Lake Havasu City, Ariz., is a family practice in the true sense of the word. Pediatrician Lorraine Byrd and her daughter, family practitioner Kelli Ward, opened the practice in August 1999, and retained Byrd's husband (and Ward's stepfather), Richard Byrd, as practice manager. 

Beginning in 1993, Lorraine Byrd practiced solo in Rockwood, Tenn. A latecomer to the profession -- she started medical school at age 42 -- Byrd was willing to start over because she and Ward had always dreamed of practicing together. Today, their practice thrives on the partners' mother-daughter relationship, as well as their transition toward becoming a paperless office.

"It seemed to me that if we were going to start a brand-new medical practice, we should take advantage of technology," says Ward, who is in practice for the first time. While a second-year resident at Garden City Osteopathic Hospital in Garden City, Mich., she did considerable research on electronic medical records (EMR). Making the conversion to an electronic system seemed like a logical move. "It was a lot less complicated than if we had thousands of patients and had to convert their records."

In the beginning, the practice retained paper charts. Once the EMR system proved to be dependable, the paper charts were shredded. Although the idea of using EMR made sense to Byrd, it was somewhat intimidating to her. "Computers were a new concept to me after practicing for seven years with traditional charts," Byrd says. "But I've really enjoyed the transfer to computers and I'm amazed at how dependent I am on them now." 

Richard Byrd, who says he had little prior computer knowledge, learned the system by trial and error. Today, he knows every nuance of the EMR, and, with minimal help from a computer consultant, keeps the office running like clockwork. The medical records of more than 4,000 patients are accessible around the office by four laptop and 19 desktop computers. 

According to Ward, the practice's EMR program is easy to use. "I wanted a program that would resemble a paper chart as much as possible," she says. "It lets you see a whole chart on one screen."

Having the charts accessible by computer has improved patient flow. A check-in clerk enters patients' demographic information and scans insurance cards into their records. For each patient visit, she produces a tracking sheet that follows the patient throughout his or her visit.

A nurse enters patients' vital signs, histories, and symptoms directly into the EMR, which includes practice-specific templates to simplify the process. Physicians also enter the treatment level, diagnosis, and codes for each patient, and transfer the information to the tracking sheet. "Our templates and programs encourage us to document everything we need to be able to support the particular level we choose," Byrd says. 

The EMR program also interfaces well with Lakeview's practice management software, and allows staff to print personalized reports. "Some programs don't allow you even to choose a font size," Ward says. "They just print generic reports. With ours, you can customize as much as you like." 

With just the click of a mouse, billing information is sent from the EMR to the practice management software. Even before the patient reaches the checkout desk, the clerk's screen shows that day's billing information, plus information on all previous bills, the total amount due, the co-pay, and, in the case of a consultation, the amount of money or number of remaining visits available to the patient. 

The checkout clerk reviews the patient's tracking sheet to verify the billing information, and to make sure that the diagnosis matches the procedure. The tracking sheet is retained on file, and at least once each day, the clerk sends the file to an electronic billing clearinghouse. 

With an EMR, lost files are a frustration of the past. Finding specific patient information is incredibly easy. 

"If a specialist calls about one of my patients that he's seeing and wants to discuss the case, I don't have to yell down the hall for the chart," Byrd says. "I just bring it up on the computer."


An EMR also makes it easy for the practice to store and retrieve reports. Currently, the Havasu Regional Medical Center, where Byrd and Ward are on staff, does not have the ability to send reports electronically. All lab reports arrive by fax or courier in paper form; once physicians have seen reports, clerks scan them into patients' charts.

Finding and printing patient education materials is also a snap. At each well-child visit, parents receive printed "anticipatory guidance" information based on the child's developmental stage. The printout includes parenting tools, nutritional information, and how-tos for determining signs of illness. 

Besides offering a standard selection of patient education handouts, the program allows physicians to type in their own material and save it for repeated use, and download educational text from the Internet and various CD-ROM programs.

Ward has devised her own education system. During patient visits, she types notes -- including diagnoses, treatment plans, and follow up information -- directly into patients' charts. She then prints her notes and gives them to the patients along with their computer-printed prescriptions. 

"The notes tell patients which issues we've addressed, what the plan is, and when to come back," Ward says. "A lot of patients bring the notes to their next visit and talk to me about them, or they say they were glad to have them because they couldn't remember what I'd told them."

Richard Byrd makes sure that all parts of this nearly paperless practice mesh. He serves as the physicians' troubleshooter, finds missing files, studies contracts to make sure the practice is paid appropriately, and keeps both software and hardware up-to-date. 

He also oversees critical backup routines. During the day, two separate but linked computers save identical data from desktops and laptops throughout the office. Each night at 10 p.m., that data is updated and saved on tape. Byrd keeps a separate backup tape for each day of the week and stores them all in a fireproof safe. Every 30 days, the entire system is written to a CD-ROM, which is kept in a safety deposit box at a nearby bank.

"Because we are in charge of peoples' medical records and they are so critical to their healthcare, we want to make sure we have them available at all times," Byrd says. "Besides all the regular backups, every morning I come in early to back up data from the previous day onto my hard drive, just in case the tape backup didn't work."

The members of the practice also find security and satisfaction working together as husband, wife, and daughter. Ward calls working with her mom "great," and the feeling is mutual.

"I'm proud of what Kelli's become and I get to watch her everyday," Lorraine Byrd says. "As a professional and as a mother, it's a wonderful thing to see my daughter giving loving, excellent care to her patients." 

This article originally appeared in the March/April 2002 issue of 

How one practice found and EMR and put it to work

Getting Off the Paper Trail


Like their counterparts in other professions, today’s physicians are realizing that customer satisfaction is a key factor in both the delivery of quality service and the ultimate success of their businesses. 

“To stay competitive in a lot of marketplaces, physicians are becoming - like most businesses today - increasingly consumer-driven,” says Edward McEachern, MD, chief operating officer of Quality Data Management in Cleveland. “Those that delight their customers the best, are in front of the pack.”

The very words “delight” and “customer” may raise the hackles of many physicians, who often see the diagnosis and treatment of disease as their primary task. But, says Donald Logan, MD, chief medical officer at Dean Health Systems in Madison, Wis., this is the direction that medicine is going. 

“You may be a good person, but the patient may not be getting the message that you’re an OK guy, you like them, and want them to like you back,” he says. “We think this is important to the business but is also good for the patient.” 

One of the best ways to find out how patients feel about the care they receive is to ask them. A growing number of practices are conducting patient satisfaction surveys to assure that the physicians are meeting their patients’ expectations and emotional needs. Following are some success stories. 

Physicians interested in conducting surveys have two basic options: they can hire a professional service to handle the work, or they can create and conduct their own. David Kirk, executive director of Intermountain Orthopaedics in Boise, Idaho, took the latter approach. Working with the practice’s management team, Kirk used a conglomeration of templates from professional journals to design an appropriate survey. 

But creating the survey was only half the battle. At first, the Intermountain front desk staff asked patients to complete the surveys at home and mail them in. As a result, the response rate was low. So Kirk asked the practice’s 12 physicians to hand the forms directly to their patients. The response rate improved; however, Kirk discovered that, if a doctor thought a particular encounter was not going well, he or she would not hand out a survey. 

Kirk has continued to refine the process, and now office staff randomly chooses five patients per doctor each day to receive surveys. Patients are encouraged to complete surveys after they have gone through the billing and collection process. The group’s medical information manager enters the data into a tabulating computer program. 

Despite such efforts, however, a group’s results are meaningless without a basis for comparison, says David Bryant, chief operating officer of the Myers Group, an Atlanta-based firm specializing in healthcare surveys and data analysis. 

“The key and real power in the results is being able to benchmark them to a standardized survey being conducted across a larger pool so you can see what you’re doing across your specialty and your office,” Bryant says. 

With that in mind Intermountain submits its data for comparison to Medical Management, a Boise-based national practice management company. 

“Each physician gets a report with all the names and data on it. It generates good discussions,” Kirk says. “Then we provide [the physicians] with articles on how they can make patients feel like they are getting their questions answered, such as using models to explain diagnoses, sitting down with the patients, making eye contact and listening.” 

Physician practices that don’t have the time or energy to create their own surveys can utilize the services of a professional organization, such as the Alexandria, Va.-based American Medical Group Association (AMGA). Under its “Patient Satisfaction Program,” AMGA works with individual practices to administer surveys over a three-week period to a random selection of each provider’s patients. Patients are handed the survey after the office visit and asked to complete the survey onsite and return it to a confidential drop box before leaving the office. Survey data is then forwarded to AMGA to be included in the organization’s benchmark database. One month later, AMGA sends a comprehensive report with overall clinic, specialty, site, and individual provider-level analyses. 


Currently about 100 medical groups - some as small as 10 physicians, but on average consisting of 200 or more physicians - are participating. The survey can be personalized with the individual practice’s logo, and AMGA provides training and data collection protocol to office personnel. The entire process typically takes three months from start to finish: one month for set-up, one month to survey, and one month for AMGA to prepare the report. 

The association runs the raw data for each physician through statistical application software and calculates the percent of responses received for each question. Results are compared to average scores and “best practice” benchmarks for 45 specialties, compiled using data from nearly one million surveys. 

“When physicians are confronted with less-than-acceptable results, first they’re surprised, then angry, then they may be resentful and unaccepting,” says Julie Sanderson-Austin, vice president of quality management and research at AMGA. “Then they say, ‘OK, what makes me different from the others who scored more ‘excellents’ and what can I do to change?’” 

Dean Health Systems, a multi-specialty group of more than 400 physicians, began using AMGA surveys five years ago. The survey costs Dean roughly $6 per physician. To be included, physicians must have 30 or more patient visits during the survey period. In 2000, Dean used handheld computers, each the size of a tissue box, to collect the data onsite. These “Point of View” boxes cost around $1,000 each. Dean owns several and rotates them among its 45 offices. 

“It’s important to know what patients think about us,” says Greg Motl, MD, chairman of the department of internal medicine at Dean. “In our organization, if patients are loyal, that’s the bottom line.” 

AMGA surveys are meant for internal use by physician practices. However, Sanderson-Austin says once groups begin doing systematic assessments of how well they are meeting customer needs, some use the results for external reporting. 

“For example, they compare them to our benchmarks, then go to a large employer group that they contract with and say, ‘Here’s what we’re doing, how we compare to the region or nation,’” Sanderson-Austin says. “They’re using them to market themselves.” 

But does patient satisfaction data really have an impact on physicians? The National Research Corporation (NRC) is banking on it. The Lincoln, Neb.-based company, which gathers patient satisfaction statistics for health plans, physician groups, and hospitals, is currently developing DoctorGuide, a project designed to measure patient satisfaction for all primary-care physicians in the nation, rate them, and develop scores that will eventually become available free to the public. 

In its first phase, NCR requested and received lists of members and the names of more than 500 primary-care physicians from health plans in Portland, Ore. NCR then sent surveys to the patients of these physicians. The results are available on the Internet, and the company is gathering similar data for the Cincinnati area. 

“We’ve done a lot to be sure the questions are measuring what they are intended to measure, and to be sure the sample is representative of the individual physician’s practice,” says Joe Carmichael, vice president of research and technology at NRC. “The response in Portland from health plans, physicians, and consumers has been very positive.” 

At Dean Health Systems, patient satisfaction data may soon affect physicians’ contracts. 

“It makes doctors uncomfortable to have patients affect their pay, but it makes me happy because it makes physicians cognizant of what brings patients in to see us again,” says Logan. 

This article originally appeared in the March/April 2001 issue of 

One of the best ways to find out how patients feel about the care they receive is to ask them