By Samantha Jefferies

CAN VISITING THE DOCTOR'S office equate to visiting the "happiest place on earth" or encountering white glove courteousness found at upscale hotels and restaurants? Service industries are constantly looking for methods to ensure customer satisfaction, retention and loyalty. The business of medicine is essentially seeking the same. Furthermore, patient satisfaction is becoming a quantitative measure for care reimbursement.
By employing techniques seen often in other service-oriented businesses such as the hospitality industry, health care entities can improve the process of patient care leading to increased satisfaction.

A six-provider family medicine group in southern California explored multiple methods to improve its patients' experiences. Prior to initiating any changes, a survey was given to patients, and the providers were surprised to find that they rated in the 75th percentile - a C average. The group was eager to go from a three-star to a five-star establishment.

Focusing on the encounter, the practice utilized every staff member's respective areas of responsibility when creating and implementing the patient visit formula. The formula consisted of three areas of focus: pre-visit, mid-visit and post-visit. Simplifying the encounter into these three stages enabled the group to apply straightforward techniques that were user-friendly, measurable and maintainable. Medical professionals are essentially scientists at heart; however, the patient-visit formula needed to be uncomplicated and effortless for ease of implementation and long-term viability.

THE PRE-VISIT 
The first step in the formula for improving the patient experience is the pre-visit, which is comprised of both direct and indirect patient interaction.

Office Environment
The office environment and surroundings indirectly affect the patients' perceived quality of care. A welcoming reception area that is clean and free of clutter gives the patient a sense of organization. This particular practice was in need of a complete overhaul of its facility as it had been at least 25 years since it had changed its decor. The remodel, which also included the addition of two exam rooms, significantly affected the opinion of new and returning patients. Although a complete office remodel obviously would be ideal, it is not financially feasible for most practices. Maintaining cleanliness and updating furniture or other features specifically in the patient reception area can create the same response from patients as a pleasant, aesthetically appealing environment. Many hotels and restaurants periodically update their lobbies for similar purposes.

Technology
The use of computers relay technological competency that is expected in any industry, including doctor's offices. Furthering the appearance of technology, the practice replaced the television in the reception area with a computer monitor that illustrates practice specifics through a continuous PowerPoint slideshow. The slides exhibit providers' photos, biographies, hours of operation, after-hours care, privacy policies and the promotion of additional services.

Technological competency also extends to the Internet and the presence of a Web site. The practice had a Web site that had not been updated in years, so they decided to change that. Each of the physician biographies has been expanded with their individual philosophies of care. Additionally, mid-level providers and photos of the recent remodel have been added to their site. The Web site now provides similar information to the reception area slideshow, and the look of the site is similar to the office with regard to colors and layout. Downloadable patient registration forms have been added to enable new patients to arrive at the office with his or her new patient forms completed, thereby, decreasing the time spent in the reception area. The practice also had their malpractice insurance carrier review and approve the site's content.

Also available on their site is a Patient Visit Agenda. Every patient is asked to complete this form prior to each visit, and it then becomes part of his or her medical record. The Patient Visit Agenda outlines the purpose of the visit and lists any changes and/or updates to their care. This form also prompts other issues that may be asked at the conclusion of the visit to be addressed during the visit. By reviewing the Patient Visit Agenda, the providers are now able to reduce the amount of time spent by focusing their purpose in the exam room.

Chart Review
The last element of the pre-visit is the simple act of reviewing the patient chart prior to entering the exam room. This small step attributed to a large increase in the patients' perception of their doctor's memory. Every individual wants to be remembered. Noting specifics from conversations had in previous exams assists providers and staff to recall that patient. Furthermore, patients will be impressed that you remembered their vacation plans or job promotion. This simple act of noting dramatically improves patient satisfaction and confirms their doctor is actually listening.

THE MID-VISIT
The mid-visit is the actual time spent with the patient. When providers enter the room, they greet the patient by name and ask a simple question from the notes taken from the previous visit. Next they begin the medical aspect by addressing the Patient Visit Agenda. Our providers also found that simply asking the patient "what else?" often uncovered secondary or hidden lists of items not written on the form. The utilization of the Patient Visit Agenda allows the visit to proceed more efficiently by covering all concerns at one sitting. The agendas have a large blank area at the top which is where our EHR system inserts the patient data when printed out. It also inserts a barcode at the bottom for automated filing when we scan the document back into our EHR system. The time saved by using this form enabled the providers to keep to their schedule as well as make possible completion of charts and other paperwork in a timely manner.

Interaction
While in the exam room, the interaction between the patient and the provider is important to the overall satisfaction of the visit. Direct eye contact, sitting at the level of the patient and mirroring body position all lead to a sense of comfort for the patient. When the patient is more at ease, obtaining information and histories becomes quicker and undemanding.

Take-aways
Finally, patients place high value on take-aways. Remember this: patients are purchasing medical services; therefore, leaving the office with something in their hands adds to their satisfaction of money well spent. So, the providers now give reminder cards and instruction sheets for follow-up care or a time frame for office communications.1 Brochures that contain facts regarding a particular medical condition or diet and exercise recommendations are also good.

THE POST-VISIT
The post-visit is the final part of the patient visit formula. Even though the patient leaves the office, there is sometimes necessary communication that must happen. The practice found that e-mail was an effective method of communication for providing patients with additional instructions or changes to treatment plans. E-mail communication also helps avoid unnecessary visits, therefore, saving time in the provider's day and allowing an appointment to be available for another patient.

CONCLUSION
This particular practice found the patient satisfaction survey tool an important gauge of success of the patient visit formula. Additionally, the survey produced a type of "Hawthorne effect" in that staff and providers were more conscious of their behavior knowing patients were rating their performance. After nine months of implementing the patient visit formula, the results of patient satisfaction surveys showed a dramatic improvement of 15 percentage points to 90 percent. Their C average transformed to an A minus. The office is maintaining their grade and the providers and staff are reporting higher job satisfaction. The medical practice may not have replaced the "happiest place on earth," but they have given patients a more comforting place to receive care.

Samantha Jefferies is the chief executive officer, RBRC Management Services, Inc. located in Mission Viejo.

1. Sample follow-up forms are available at www.familydocs.org/practice-resources/forms-center.php