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When patients enter a medical practice office, they interact with as many as three or four staff members before they see the physician the receptionist, an administrative clerk, a nurse, and a lab tech. Bad experiences with any one of them could turn some patients off, even if they like and respect their doctor.
That is why a program to create patient-centered care and improved communications should encompass the entire staff, not just physicians or other clinicians, says Andrew L. Epstein, MD, a principal of HSC Associates, a Cambridge, MA-based consulting firm that specializes in the interpersonal aspects of care.
The organization also should be aligned around patient satisfaction goals, he says. For example, performance assessment and incentives should address patient satisfaction goals. Scheduling and other systems should be geared toward meeting patients’ needs, he says. (See related story, p. 47.)
In interviews with patients, Epstein recalls a common refrain, "When I finally get to the doctor, everything is fine." But after facing a long wait, a rude receptionist, and delayed or lost test results, "some people will actually be dissatisfied enough that they will leave their physician," he says.
Epstein and his partner, Matthew A. Budd, MD, brought his team-oriented program to a medical group in Torrance, CA, where staff and physicians attended workshops together. The result was better morale, a greater sense of teamwork, and higher satisfaction for patients, physicians, and staff, says James D. Slay, Jr., RelD, director of behavioral health and collaborative care for HealthCare Partners, a multispecialty medical group based in Los Angeles that has 37 sites and 280 physicians.
"[The program] wasn’t just a matter of clinical people getting together and idealizing," says Slay. "The focus [developed into a] greater concern for the patients when they worked together than they were able to show as individuals."
"That is the goal of training for physicians and staff members, says Epstein. While they learn specific skills, more importantly they gain a new orientation toward patient care, he says one that stresses "not diseases to be fixed but customers who must be satisfied."
The patient satisfaction program began just before the merger of two small primary care sites of Bay Shores Medical Group, which has since become region three of HealthCare Partners. The six physicians, social worker, and staff of 25 met on a couple of Saturday afternoons to develop a vision, values, and standards central to patient satisfaction.
The vision: "Providing the highest quality care and patient satisfaction in a nurturing environment."
Then, in two-hour lunch programs for five successive Thursdays, the group met and began trust-building exercises, talking about issues related to their own work satisfaction and interpersonal relationships. "Loyal customers are produced by a loyal staff," says Epstein.
For example, team members learning about listening skills then role-play with one person trying hard not to listen to what the other is saying. "We take them through different steps so they become aware of when they’re distracted, how to recognize it, and how to refocus," Epstein says.
In another exercise, physicians and staff members listened to someone talk for two minutes, uninterrupted, on any subject. "It was a practice in realizing that in most cases people exhaust what they need to say in a short period of time," says John Roohan, MD, lead physician in the medical office. "You can really let people say what they need to say and not be concerned about them going on and on in a time-pressured environment."
The program also helped physicians gain better insight about their patients, says Phillip Valentine, MD, a dermatologist who participated. "We were learning about patient perspectives, about what patient expectations are, and what we could do to further reach those goals," he says.
Ultimately, those goals of patient-centered care are tied to physician compensation, says Roohan. The practice has a "provider performance review committee" and a bonus system that is based partly on patient satisfaction surveys and staff and peer evaluations, he says.
Instruction on interpersonal communication and patient-centered care helped the newly merged office open with a sense of purpose, says Roohan. But the education is ongoing.
In monthly "learning conferences," a physician-staff team presents successful and problematic patient encounters, including role-playing and discussions of what went right and wrong. "A patient who was difficult for the doctor was likely to be difficult for the receptionist and medical assistant as well," says Epstein. "That was one way to build team consciousness. "They began to develop project teams to address problems in the care process."
For example, the receptionist might begin describing a difficult patient encounter by saying, "When the person called, I could tell they were upset. And this is what I said."
With this process, weaknesses in the group’s systems, such as scheduling, billing, or the laboratory, can be more easily detected and fixed, says Epstein. And improved communications can have a broader impact than the 15-minute doctor-patient encounter. "Skills that build trust and satisfaction are not doctor or nurse or receptionist skills," says Epstein. "They’re human skills."
The conferences provide "a way of reinforcing the communication skills and reinforcing the idea that everyone’s ideas are important, everyone contributes to patient care," says Roohan.
Physicians also must constantly remind themselves to use the listening and communications skills they learned, says Roohan.
"It takes a lot of learning and practice to be able to be calm enough with yourself to back down and say, I’m going to just let this person talk,’" he says. "Some days it’s easier than others. But it’s definitely worthwhile in the end."