What happens when patients are unhappy about the service that your hospital provides? Some patients leave, requiring you to invest additional resources:

1. Time and money needed to attract patients to take their place.
2. Extra time spent with the replacement patients to explain how your systems work.
3. Extra time and money spent creating the systems needed to care for patients in your organization, e.g. registration and medical record systems.

Other patients continue with you, but do so unhappily, and it shows. They have "an attitude" that makes them more challenging to you and your colleagues. They take more time, as they are reluctant to trust what you do or say. They look for ways to test you, resist you and annoy you.

Some reasons why patients are not satisfied:

You aren't what they expected.

Don't refer to yourself as "best available" unless you can live up to that name. If you are launching a new service or philosophy, don't promote it until you have tested it. Above all, don't let your long-term goal become your patient's near term expectation by promising more than you can possibly deliver.

實例：A patient told about arriving at a physician's office to have a consent discussion for a vasectomy. He and another man were waiting in the reception area. The other man was called in first. Then he was called, and taken to the physician's office, where the physician and the other man were waiting. The physician proceeded to have a consent conversation with both patients simultaneously.

They are distracted by their own anxieties.

實例：A few years ago, while traveling out of state, I was in a serious automobile accident. In the Emergency Department, a physician was preparing to suture a wound in my head. As concerned as I was about my injuries, my greatest feeling of anxiety at that moment came from the fact that I did not have a sheet covering my legs. Fortunately for me, they physician asked me an important question. "Is there anything I can do to make you more comfortable before we begin?" I wished for a sheet; he found one and placed it over me. My concern about whether or not he was a good doctor quickly melted away because he took a moment to find out what my needs and fears were before he did what he needed to do.

They are distracted by interruptions and as a result, can't listen.

While you may be immune to the needs of your processes and systems, patients often aren't. You understand the need to interrupt a consultation to take a call from another clinician. Your patient may not. You understand the need to interrupt a patient's registration in order to answer a colleague's question. Your patient may not. You understand the need to have a colleague take over the care of a patient so that you can take a break. Your patient may not. At the very least, minimize the number of interruptions permitted during a patient's initial visit with you. Then, explain why some interruptions may be essential. "Although I don't like to leave my beeper on during a consultation, when you are here for an evening appointment, my beeper may go off if I am on call for the hospital that evening."

You don't believe in them, so why should they believe in themselves?

If you are pessimistic about your patient's ability to do well, follow through, etc, your patient is likely to sense it. The secret of medical success: "To inspire confidence. The doctor who possesses this gift can practically raise the dead."

Someone on your team has created anxiety about your operation.

When patients don't buy in, it's often easier to try to blame someone or something else rather than conduct a self-assessment.

Scenarios

So, what can we do to manage the situation? In the following, I present three scenarios from the literature about the different ways that organizations have coped. The first scenario is a traditional response, consoling staff that more has to be accomplished with fewer resources, and extolling the virtues of staff training related to treating the patient as a customer. The second scenario uses online consulting with doctor-patient email to enhance the interaction. The third scenario moves away from the self-governance which is the usual method in most organizations today, and sets out to influence doctor behavior by grading, credentialing, and legislation. The final scenario is a view of the future, which is already occurring in pasts of America: concierge primary care where better service is based on higher payments by the patient in the style of a health-care club.

Senario 1: the Patient as Customer

Central to patient satisfaction is the concept of patient as customer. A customer, for example, is now often identified in most other businesses as either external, internal or intermediate. In a medical practice, that means the patient is the customer, but so are the patient's family members and friends, referral physicians, insurance companies, suppliers, practice employees and staff. Just one dissatisfied person in this universe of customers can have potentially negative consequences for the practice. Conversely, maintaining and continuously improving the satisfaction of all these customers contributes to success.

But patients' own unreasonable behavior causes some problems. Many patients make an appointment for one child and then expect the doctor to see a second child also during the same visit and for the same fee. Or they make an appointment for a sore throat and then expect to be treated for other, more complex conditions, too. Things like that are what make doctors run behind schedule.

The Power of Communication

Communication is the heart of quality service in health care: 55 percent of what we learn from others comes from their body language, 35 percent from their tone of voice, and 7 percent from the words they say. To send the right message, nonverbal signals such as eye contact, facial expression, body posture, hand gestures, touching and interpersonal distance must be appropriate and consistent with the words being spoken.

One aspect of communication–listening– deserves special attention: 75 percent of oral communication is forgotten, ignored or misunderstood. Effective listening consists of hearing, attention and understanding. To understand, we must consider the context of the message and the verbal and nonverbal clues given by the sender. Good listeners also pay attention to their own physical stance, body movements, eye contact and encouraging words and gestures. To improve listening, identify and eliminate "listening blocks," which come in four categories:

1. Listeners with psychological blocks are easily distracted, stressed or prejudiced.
2. Listeners with physical blocks may be suffering from impaired hearing, drowsiness or overwork.
3. Environmental blocks include noise, an acoustically poor environment or uncomfortable temperatures.
4. Personal expectations can also get in the way if the listener believes the speaker has low status or that the message is routine or bad news.

When Patients are Difficult

The ultimate test of communication skills may be in dealing with patient complaints and angry patients. In other businesses, it has long been gospel that customers who complain can be valuable assets in identifying and fixing problems before more customers are lost, and that the way a complaint is handled can leave a customer even more satisfied. 96 percent of unhappy customers do not complain; most of them simply take their business elsewhere. Each of these dissatisfied customers then shares the negative experience with about 10 other people. For health care providers who do it well, successful complaint handling can be a chance to leapfrog their competitors.

Scenario 2: Online Consultation

The rapid growth in email gave hope that electronic messaging would spread to healthcare as well. However, problems such as lax security and lack of control over the types of messages that doctors received quickly became apparent.

Doctors usually are blamed for slowing the spread of electronic communication systems. However, most patients still interact with doctors the old-fashioned way -- face-to-face or over the phone. Many patients are reticent about turning on their computer to contact their doctor, and some are frustrated when they do. Even those who regularly use email for personal matters may not know how to navigate or interact on a Web site.

The fact that only a fraction of patients actually use online messaging when it's available is surprising, given that national surveys indicate the public is clamoring for the chance. A 2002 Harris Poll found that 70% of patients said they wanted online access to their doctors, and nearly 40% were willing to pay for the service. Yet, when offered the opportunity, a much smaller proportion ends up using it.

Patients are not as concerned about privacy as some analysts had predicted. They mostly are uncertain about how the messaging process works. Some patients simply forget to use the service because they need a doctor so infrequently.

The main barrier for doctors, however, has been a reluctance to offer a new service without getting paid. Now that more insurers are willing to reimburse doctors for the service, that attitude may change.

Most of the messages are about simple matters, such as renewing a prescription or scheduling a laboratory test. Only a few patients have asked about more complex diagnostic matters. The messages, written in a patient's own words, generally are clearer than those phoned in and filtered through the office receptionist. Electronic messages about administrative issues were resolved twice as quickly as those handled in person or by phone. The security of those messages is at least as good as that of paper records and the malpractice exposure is no greater than with undocumented phone calls.

Scenario 3: Behavior Grading for Credetialling

Studies have shown that poor bedside manner and workplace behavior can diminish quality of care. A lot of patient recovery depends on mental attitude. Statistics on poor behavior by doctors are hard to find, but the problem may be growing. Medicolegal problems are now 30 percent due to doctor's behavior problems, twice that of a decade ago.

A physician-behavior bill is under consideration in Massachusetts to establish a state-run grading system for physician behavior. Doctors who fail could have their hospital credentials revoked, and repeated failures could result in a suspended medical license. The bill was written by Harvard specialist Dr. Lucian Leape, author of the 1998 government-commissioned report that estimated that up to 98,000 people die annually from medical errors in the United States. The bill requires the state Board of Registration in Medicine to develop a list of behavioral criteria, including rudeness, demeanor with nurses, punctuality, behavior with patients and vulgar remarks, and evaluate doctors every two years.

Scenario 4: Concierge Medicine

實例：Since childhood Dr. X had wanted to be a family doctor, and he'd pursued his ambition diligently. Nearly 20 years of hard work had earned him a thriving practice. His 2,600 patients were devoted to him. Mornings were a whirlwind of hospital visits. Afternoons were crammed with appointments. Evenings he tackled a mountain of paperwork. At 47, Dr. X was busy, beloved—and miserable. He worried about tests that might have gone astray in the rush or patient concerns that went unsaid as he dashed from one exam room to the next. "I have always loved medicine," he says, "but practicing it became a nightmare."

Then he closed his practice, and joined concierge medicine.

Now Dr. X has a roster of 600 patients, each of whom pays an annual fee on top of any insurance reimbursements. That buys white-glove medical care: same-day appointments, friendly nurses who know patients' names and the names of their grandchildren, and even home delivery of prescriptions when needed. The doctor is always in, and he has plenty of time to listen. Stuffy nose keeping you awake? Call the doc at home. He'll make a house call. "This is the way medicine should be practiced," says Dr. X. "My patients are very willing to pay the price."

A Controversial New Kind of Medical Practice: Luxury Primary Care.

Not long ago the notion of the well-to-do paying out of pocket for luxury medical care was dismissed as an elitist fad. But as managed care has tightened its grip on medical costs, physicians' workloads have exploded and reimbursements have fallen. Malpractice premiums have also soared, further squeezing doctors' income. Internists and family practitioners have been hit particularly hard. The average primary-care physician now sees a patient every ten minutes, according to the American Academy of Family Practice, while net income fell 16% between 1998 and 2000. More than a quarter of the primary-care physicians surveyed expected to quit within the next two years.

To a doctor fed up with trying to manage a medical practice, concierge medicine offers a business model that is counterintuitive: fewer patients, more money. Physicians' patient loads are limited (to 600). Patients' annual fee (of $1,500) covers a comprehensive annual physical and other preventive care, such as weight-loss and smoking-cessation counseling. All other treatment for acute or chronic illness or disease is covered by a patient's private insurance or Medicare. The founder of this business was a patient who says he was frustrated with the medical care he was getting. "I'm old, I'm fat, I smoke, and I'm rich," he says. "I got fed up with the lousy service I was getting from doctors. You wanna know the last straw? I was standing at the Plexiglas window in some guy's office trying to get the nurse's attention. And there's a sign taped to the window: do not tap on the window. I'm sick. She's ignoring me. And I'm afraid to tap on the window! What kind of business can survive with that kind of service? "

Concierge medicine first made headlines in 1996 with the launch of a practice by a former team doctor for the NBA's Seattle Supersonics, who was convinced that people would pay for the kind of extraordinary medical care usually reserved for professional athletes. Slackers—and those seeking to ease into retirement—are not suited. Taking good care of a small number of patients is still hard work and not a lot of doctors are cut out for this kind of practice.

Physicians—and their nurses and office managers—who are admitted to the network undergo substantial retraining. Doctors and nurses are so overworked that they've come to regard the patient as the enemy. They have to work hard to change that attitude. So newcomers spend a week having their bedside manners polished. The motto: The patient is now a paying customer. The service is priced at about the cost of a health-club membership.

Patients enjoy a lot of old-fashioned—and newfangled—benefits. They get a comprehensive annual physical with plenty of time afterward to discuss the findings with the doctor. Doctors regularly call patients to check on whether they are following suggestions to lose weight or stop smoking. When a patient is referred to a specialist, the nurse calls the patient after the appointment to see if the visit went well.

The system does not allow its physicians to use answering machines or answering services. All doctors are available to their patients around the clock; patients get their home phone numbers and their cell-phone numbers. "My wife was recently diagnosed with a serious illness, and our doctor was on top of the situation from the start," says Patient BL, 64, a real estate broker who joined several years ago. "He recommended the specialists, and his office made the appointments for us. He followed up on all the tests. In fact, he called us in the car on our way home after the CT scan. When you're scared and nervous, that's the best medicine in the world."

Patients get other benefits too. Medical records are encoded on a CD and updated regularly, so patients can have them handy if they become ill when traveling.

Guidance is given about how to decorate the doctor's office. Dr. X has a waiting room that is lushly appointed with expensive furniture, bowls of fruit, and a big-screen TV. Gone is the reception desk with the Plexiglas to shield the office staff from the sickly. Nurses greet patients warmly by name and usher them into a private room. Patients never have to perch on an exam table, shivering in a paper gown, to have a discussion with the doctor. Dr. X outfitted a room as a cozy den with overstuffed furniture and plants; he says patients are more comfortable talking after the exam in a homey setting.

To ensure consistent quality, the system continually monitors its doctors. Investigators posing as new patients regularly book appointments and even visit their offices, then rate the quality of service. Standards are high.

Appendix: Successful Strategies for Patient Satisfaction

• Keep a professional appearance.
  • For many patients, there is a relationship among cleanliness, neatness and health.
• Convey positive nonverbal messages.
  • Greater patient satisfaction occurs not only with more touch but with more nonverbal attention. This shows patients you want to establish a pleasant relationship or bond with them.
  • Touching is a ritual that establishes your personal relationship with your patients. Reach out and offer a handshake as you greet the patient. It shows you are a caring person.
  • Don't touch an angry person.
  • Use eye contact. Look at patients as you listen or speak.
  • Use an open body posture.
  • Use nonverbal encouragements such as nods and gestures.
• Acknowledge the patient immediately.
  • Greet and comfort first, do paper work second. Don't let patients wait, even if you are busy. Show that you will assist them shortly and let them know you are aware of their presence.
  • Give your full attention to those patients who are present. If you must answer the phone, do not hesitate to put the patient on the phone on hold while you address the patient in your immediate presence.
  • If you are talking with another staff member, excuse yourself immediately and address the patient. All staff must recognize that the patient comes first.
  • End all personal conversations on the telephone immediately upon the approach of a patient.
• Introduce yourself.
  • You, too, are a person with an identity to which the patient can relate. Give the patient your first name and describe in simple terms what you will doing.
  • Reinforce the spoken use of your name with a visible name tag, a name plate on your desk or business card.
• Greet the patient by name.
  • Use the patient's name to personalize the service you provide.
  • Open conversations with patients with a friendly greeting. For example, "Good morning, Mr. Smith." (Smile.) "I am Brenda, your receptionist. I need some information for your record. It will not take long." (Smile.)
• Use a natural conversational tone.
  • Speak with a calm, firm, caring and confident tone. Do not raise your voice in anger. Speak clearly and distinctly.
• Pay attention to details.
  • Little things are important and send signals to patients about who you are.
• Give the patient your full attention.
  • Staff members should not interrupt when you are with a patient except in emergencies.
• Use appropriate language.
  • Use language the patient will understand. Don't talk about irrelevant subjects. Use the time to explain procedures and routine tasks.
• Tell the patient what you can do.
  • Do not begin comments with statements about what you cannot do. Provide choices or alternatives that you and the patient have.
• Inform, instruct and explain.
  • Provide as much information as the patient is interested in knowing, such as basic and elaborate instructions, explanations and directions.
  • People respond better when they are informed about what is going to happen to them. Uncertainty causes fear, worry, confusion.
  • Explain delays and changes truthfully.
  • Explain why you are performing certain tasks The informed patient is likely to be more cooperative.
• Do something extra.
  • Take the initiative and go out of your way to provide the extra touch.
• Build a partnership with the patient.
  • Partnership-building goes beyond informing and soothing the patient. It is involving the patient in a participatory relationship by enlisting patient input.
• Show appreciation.
  • Show and tell patients how much you value them.
• Be discreet.
  • Respect the patient's privacy.
• Be competent and knowledgeable.
  • This includes performing tasks quickly and accurately.
  • Patients want to know that you are up to date and have the latest clinical information.
• Acknowledge errors quickly.
  • Don't try to cover up mistakes with excuses. Admit your error and start solving the problem.
  • Report patient service problems you see or experience to the person who keeps track of these incidents in your organization.
• Look for small opportunities.
  • Going out of your way for a patient requires that you maintain technical, administrative and procedural knowledge. You should know when and how far you can depart from established protocols, guidelines and procedures.
• Make the last impression count.
  • Use a positive manner to wrap up the interaction.
  • Don't end the interaction on a hostile note.
• Make follow-up contact.
  • Following a procedure or treatment, it makes good business and therapeutic sense to check on the patient's condition.
  • Document telephone calls.
• Handle complaints effectively.
  • Take the patient seriously. Apologize for any inconvenience. Tell the patient that you will do everything possible to solve the problem.
  • Maintain your composure, no matter what the patient says to you.
  • Give the patient the opportunity to describe the full complaint without interruption. Avoid the temptation to retaliate against patients who are rude; focus your energy on determining the facts and on evaluating the action the patient wants you to take.
  • Help the patient save face if it becomes obvious that he or she is in the wrong.