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Patient Satisfaction: When You Don't Satisfy


Patient satisfaction surveys are becoming more common in private practice. What do you do when your patients are unhappy?

Patient satisfaction surveys proliferate, but what should you do when your results indicate dissatisfaction with the physicians in your practice - particularly with their customer service skills?

Practice management consultants warn not to take your patient base for granted. Satisfied patients benefit your practice with patient loyalty and additional referrals.

The Medical Group Management Association (MGMA) recommends that every provider perform as if patient satisfaction were the key to protecting their practice’s existing revenue base and generating new market share. Some practices determine physicians’ compensation formulas based on their patient satisfaction scores. And keep in mind that satisfied patients usually don’t litigate.

So if your patient survey results are less than stellar, you can’t afford not to respond. A recent Commonwealth Fund study revealed that differences among the ways in which individual physicians operate their practice sites account for the majority of variability among patient care experiences - providing further evidence of the importance of focusing on patient satisfaction as a means for improving healthcare system quality.

Once you identify the specific problem areas in your practice, it’s important to develop a plan of action and follow through with it.

Shadow coaching

In shadow coaching, a trained consultant accompanies a physician for a day’s observation.

Meryl Luallin, an experienced shadow coach and partner in Sullivan/Luallin, Inc., a San Diego-based patient satisfaction consulting firm, explains how this works: “At the beginning of each encounter, the doctor comes in and introduces me as Meryl Luallin, or I introduce myself. Then the doctor explains that I am writing a report on a day in the life of a doctor - which is the truth - and we ask the patient if I can stay during the visit. The patient generally says ‘yes.’”

Luallin adds that shadow coaches take specific precautions to ensure patient privacy is protected at all times. “If the patient hesitates or says ‘no,’ I leave,” she says. “Furthermore, the coach does not write down the patient’s name. There is no way that the patient is ever identified in any publication or in the report that goes back to the doctor after the shadow coaching is completed. … While the coach does hear the presenting problem of the patients, she is never allowed to look at the patient’s chart. There is no breach of confidentiality because we ask the patient at the outset.”

After a day of shadowing, the physician receives direct, one-on-one feedback on her interaction with patients. The coach makes specific suggestions for patient service improvement.

Physicians who have the most trouble connecting on a personal level with patients stand to gain the most from shadow coaching, says Luallin: “The ideal shadow candidate is a practitioner with consistently low ratings concerned about the consequences and willing to explore options.”

The problems shadow coaches uncover aren’t always major, and they may be as simple as getting physicians off “auto-pilot” behavior, such as repeating the same instructions in a monotone voice. Luallin says one physician she coached whose patients had criticized for poor communication skills found that when he stopped speaking with his hand over his mouth, fewer patients asked him to repeat himself.

After observing a physician, the coach prepares a written report, providing the doctor and the practice’s medical director recommendations for improvement. Approximately two months later, patients are again surveyed to determine the effectiveness of implemented changes and to identify which areas may still need work.

Some common patient service suggestions include shaking hands with patients when first greeting them, making eye contact, taking a seat after entering an exam room, asking how you can help the patient, and actively listening to a patient’s concerns. It is also important not to interrupt patients when they are speaking, as this generally makes patients feel they are being rushed, says Luallin. A physician should also make a practice of writing down their instructions, since many patients often forget what they are told after leaving the office.

System analysis

Most experts agree that to be effective, shadow coaching must be part of a larger strategy of regularly gathering patient feedback. Jack Valancy, a practice management consultant in Cleveland Heights, Ohio, agrees that experienced shadowers can provide valuable feedback. “Obtaining a different perspective can be very useful for detecting, diagnosing, and designing solutions to problems,” he says. But he adds that not all patients are willing to participate in a management improvement project. He prefers the broader system analysis approach.

With this method, a consultant walks through a practice to observe how a patient is treated, asking probing questions of staff and physicians along the way. Consultants evaluate a practice as a functional unit with many parts rather than focusing solely on physician behavior.

Consultant Mike Parshall with The Health Care Group in Plymouth Meeting, Pa., agrees that the system analysis approach is more effective. “Practices that are concerned about patient satisfaction and give it more than lip service put together a whole program to attack the problems,” he says.

Mystery patients

MGMA also recommends using “mystery patients” as part of more extensive practice evaluation programs. Mystery patients can pinpoint detailed information regarding how well a given practice responds to patients by identifying individual physicians’ strengths and weaknesses. Mystery patients, who pose as real patients to observe physician behavior without the practice’s explicit knowledge, are trained evaluators who look beyond generalized survey data to identify specific problem areas and recommend practical strategies.

If you choose this evaluation method, inform physicians and staff in your practice that mystery patients are scheduled to visit as part of your evaluation program. If you wish, practice management consultants can ensure the identities of mystery patients remain unknown.

Introduce this evaluation method to your practice as a positive self-development tool. Present it as a method of gaining feedback so physicians and practice staff can be rewarded for their strengths and coached in areas in which they may need improvement.

According to MGMA, many practice groups cited for their best practices maintain a year-round, continuing schedule of mystery-patient assessments.

Standardized patients

While serving as head of a primary care network associated with the University of Nebraska in Omaha, Jeff Susman used standardized patients to give the physicians in his practice feedback on their patient service skills. Medical schools and teaching hospitals typically use standardized patients as training tools for students and residents. According to Susman, “Standardized patients provide a better level of feedback than just any patient.”

Currently chair of the Department of Family Medicine at the University of Cincinnati, Susman says his colleagues in Nebraska were critical of his use of standardized patients. Some physicians claimed standardized patients do not possess the expertise to judge patient services. Nevertheless, Susman says the effort provided useful perceptions on everything from appointment scheduling to how individual physicians interacted with patients.

Another evaluation method is simply to call individual patients in your practice and ask them if they would like to provide anonymous patient feedback during their next office visit. Once they agree, send them a letter explaining your program as well as an evaluation form for them to complete and mail back to you after their visit. This method allows practices to drawn on their own patient base for feedback. Use modest gift cards for use at coffee shops, movie theatres, or restaurants to thank your patients for their time.

Regardless of which evaluative tool you prefer, experts recommend these common techniques for improving patient satisfaction:


  • Regularly conduct patient surveys to obtain feedback. Study your results and determine which of your procedures and practices need improvement. Your aim should be to improve quality rather than place blame on any particular staff member.


  • Inform your practice of patient feedback. Work with physicians and staff to devise specific ways to address your problem areas, and create a schedule for completing your plan of action. “When physicians and staff understand the problem and develop their own solutions, they are much more likely to make the solutions work to solve the problem,” says Valancy.


  • Devise specific patient-service standards. These should cover the four phases of a patient encounter: establishing rapport, eliciting information, educating the patient, and ensuring compliance. Staff performance standards should include making a great first impression, using appropriate telephone etiquette, handling patient complaints, and creating a team environment within the practice. Take time to describe these standards and incorporate them into staff job descriptions. Some practices use improved scores on specific patient survey questions as part of annual performance appraisals.


  • Decide which evaluative methods are right for your practice. These methods may include systems analysis, shadow coaching, mystery patients, standardized patients, mentoring, and training sessions.


  • Use follow-up patient surveys. After putting specific improvements into place, survey patients again on a regular basis to determine if your changes are making a difference or if further steps are necessary.


What matters most is not which method you use, but which will produce the evaluations you need to improve your service delivery. Says Parshall, “Get everyone in the practice trained, involved, and concerned about patient

Joan Szabo has more than 20 years of experience as a business writer and editor specializing in medical and healthcare topics for physicians, consumers, healthcare organizations, and pharmaceutical companies. She is the author of Physicians Legal Handbook and Maximizing Practice Profits, bimonthly guides to practice management for physicians. Joan previously researched and wrote the first draft of the Joint Commission on Accreditation of Healthcare Organization’s book on the use of technology to improve medication safety. She can be reached via

This article originally appeared in the May 2006 issue of Physicians Practice.

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