Today’s consumers experience high levels of service from Internet booksellers who seem to know them personally, credit card companies who process information instantaneously and banks with ATM machines that seem to always be just where they need them. So it’s no surprise that when their physicians and other health care providers ask the same questions repeatedly, can’t find lab results and rarely seem to be available when needed, it affects their willingness to return.

Unfortunately, the quality of care you provide may do little to make up for shortcomings in the quality of service patients receive when they visit your practice. Research suggests patients have a hard time separating the two. A study by the Picker/Commonwealth Program for Patient-Centered Care suggests that patients define “care” in terms of service. Among the measures patients identified were respect for a patient’s values, preferences and expressed needs; access to care; information, communication and education; and continuity.¹

This article will provide you with the information and tools you need to assess and improve your practice’s current level of service.

Identifying your “moments of truth”

To better understand the level of service your practice provides, you can perform a simple “moment-of-truth” analysis with the help of your practice partners and staff. In health care, a moment of truth is a moment when the patient experiences some interaction and forms a judgment about the quality of the practice. Of course, good service is always important, but at moments of truth it’s crucial.

For example, a moment of truth occurs when the physician walks into the exam room. The physician’s behaviors and body language in the first few seconds set the stage in the patient’s mind for a good or bad interaction. The patient may notice whether the doctor makes immediate eye contact or enters looking down at the medical record, and whether the doctor gives the impression that he or she is relaxed and ready to listen or harried and just wanting to move things along.

The purpose of analyzing moments of truth is twofold: to create a service mind-set in your practice and to identify some priorities for improvement. The sample moment-of-truth worksheet on page 43 can guide your analysis. The first column lists potential moments of truth (e.g., when patients call for an appointment), and the second column suggests ways to assess them using observation or measurement (e.g., the number of rings before the phone is answered). In addition to the suggestions listed on the worksheet, you may want to develop some of your own ideas. One way to do this is to post one moment of truth per day on bulletin boards in central locations and encourage others (including patients!) to jot down assessment ideas as they think of them. Be sure that the assessment items you come up with are stated in observable or measurable terms as seen through the patient’s eyes. For example, “friendly staff” is too vague. Say instead, “patients get the impression that the staff enjoys working with patients.” And although “time spent searching for medical record” is measurable, it is not seen through the patient’s eyes. Rather, “time spent in the waiting room before being called back to exam room” captures the patient’s experience of service in the office.

What level of service are you providing?

Once your worksheet is complete, there are a number of simple ways you can measure and assess your practice’s level of service for each moment of truth you’ve identified:

• Observation. Look around your office. Is the telephone first answered by a person or a machine?

• Automated data collection. Some telephone systems can automatically keep track of average time on hold.

• Pencil-and-paper strategies. For example, you might have a nurse write the rooming time on a note and stick it on the exam-room door, and then have the doctor write his or her time of entry on the same note and drop it in a box for later summary analysis.

• Patient feedback. Give patients a colored marble as they exit and ask them to respond to the item of the day (e.g., “the doctor really listened to me today”) by dropping the marble in one of five glass cylinders corresponding to their response – strongly agree, agree, neutral, disagree or strongly disagree. The result is a bar chart of service satisfaction at the end of the day!

• Personal experience. Call in on the normal appointment line to see for yourself how quickly the phone is answered and how pleasant the greeting sounds.

However you choose to assess your practice’s moments of truth, keep it simple, involve staff in coming up with creative approaches and have some fun. See your practice through the patient’s eyes. Don’t get hung up on statistical questions or worry about getting large samples. You are not writing a research paper; rather, you are becoming more aware of trends in the service you provide to your patients.

Setting priorities for change

After measuring and assessing your practice’s level of service, you may find that your practice’s performance is far from ideal. If you want a different level of service in your practice, you will have to change something. But rather than trying to fix all the problems at once, you will need to set some priorities.

It is important to involve your practice partners and staff in this priority-setting process just as it was in the moment-of-truth analysis. If you can arrange a large staff meeting, do that; but there is no need to give in to the tyranny of another meeting. The information from the assessment could be distributed in a brief report that asks everyone to rank or vote on topics for improvement via a bulletin board or form. Or you could appoint a small group that represents a slice of professional and office staff to go through the items and select eight or 10 that could then be put before the entire staff; then use the input to narrow the choices to two or three for initial action. You might even consider involving a few patients you know will be constructive in providing input.

As you set priorities, ask yourself the following questions:

• In what areas is our performance far from ideal?

• What improvements do we think our patients will notice most?

• Where do we think we can be successful in making change?

• What groups of clinicians and staff should we involve in each item, and what is their readiness to change?

Don’t spend a lot of time agonizing over what to put first on your list. Just pick something that matters and where there seems to be a critical mass of partners and staff willing to do something about it, and get started.

Keep in mind that after you choose an area and make improvements to it (see the section “Conducting tests of change,” below), you will choose another area and repeat the process. Service improvement is a never-ending task. Each round of focus and improvement builds momentum toward a mind-set of service excellence.

Conducting tests of change

Once you’ve completed a moment-of-truth analysis and identified your priorities for change, you can begin to actually make changes in your practice’s level of service. The illustration below presents a commonsense approach to improvement made up of rapid cycles of small “tests of change.”

As you can see in the model, improvement begins with focus – picking something to work on. Next, the current level of performance needs to be measured in a simple way that doesn’t require the rigorous measurement of a research study (the moment-of-truth assessment typically provides an adequate baseline measurement). The essence of improvement is change, so the next logical step is to intervene and try something different. Then measure the level of performance again. If more improvement is needed, intervene and change something else. The point is to use common sense, try various things and measure frequently. Keep these tests of change going until you are more satisfied with your level of performance than you were when you began and you feel ready to focus on another area. [For an example of a test of change that might be done in a family practice, visit this article online atwww.aafp.org/fpm/20020400/41buil.html.]

The following four discussion questions (incorporated in the worksheet on page 45) will help guide you and others in your practice as you conduct your own tests of change:

1. Aim setting: What are we focusing on now, and what is our goal? Describe the area of improvement you want to focus on (your chosen priority), and determine the point of satisfaction for that area. State the aim in patient-oriented terms, and set a measurable goal. You shouldn’t set perfection as your standard, but your goal should be ambitious enough that you have to think of fundamentally different ways of doing things and that you wouldn’t be embarrassed to tell your patients about it. For example, wouldn’t you prefer your patients see that you set a 90-percent goal for answering the phone within five rings rather than a 50-percent goal?

2. Measurement: How will we know if we are making it better? The key is to choose practical measurement over perfect measurement. Keep it simple. Think of measurement as a feedback loop, and make the feedback rapid. For example, if you are working on listening to patients more, get their feedback immediately as they leave rather then waiting weeks or months for data from a more formal, mailed questionnaire. Often, it is not so much the absolute level of what you are measuring that counts but simply whether it is trending up or down. Also, consider additional “balancing measures” – other things that could get worse while you are making changes. For example, if you are working to reduce patients’ time in the waiting room, you should also measure overall visit time and/or time in the exam room; reducing time in the waiting room doesn’t do any good if the patient just waits somewhere else.

3. Idea generation: What changes do we think will make it better? Ideas for improvement can come from a variety of sources. You may have read about something or heard about it from a colleague or at a conference. The idea may come from some other setting (e.g., you may be impressed with the way some other business handles scheduling and decide to bring some of its approaches into your practice). The idea could also come from logical thinking (e.g., it makes sense that patients will feel better served if the nurses write the phonetic spelling of the patient’s name on the chart and the doctor fully scans the history, closes the chart before opening the exam-room door, enters making eye contact and greets the patient, correctly pronouncing his or her name). Idea generation might also involve creative thinking that challenges the way things have always been done (e.g., providing flu shots in a drive-up service in the parking lot).

4. Testing: How will we carry out progressive trials of our ideas? The only way to know if an idea will work for you is to try it and see what happens. Think small-scale and rapid-cycle: What can I do in the next few days that will give me more insight into whether this idea will work for our practice? Quickly plan a test; carry it out; reflect on the results and your experience doing it; and then decide if you want to keep going with the idea, modify it and try again, or discard it in favor of another idea. Expect to conduct several such cycles, maybe with several different ideas, in order to reach the goal stated in your aim. Remember that others are more likely to go along with change if they are involved in planning it. Don’t get attached to any particular way of doing tests of change; allow others the joy of working out the specifics. Work initially with the willing, but keep everyone informed of what you are doing so that no one is surprised.

The criticism of this approach to improvement is that it is “unscientific” and that, in the end, you won’t know which of several changes made the biggest difference and won’t be able to generalize the findings without randomization and more rigorously collected data. This may be a valid criticism, but so what? If a small test of change improves some aspect of patient service, you’re better off than you were before. We rarely demand to see the evidence supporting the status quo, but we often subject change ideas to a higher standard. We are not talking about clinical interventions here – where certainly a higher standard of evidence should be adhered to – we are talking about improving the patients’ experience of care and service in the practice.

A service mind-set

Providing good service is not just a frill in family practice. It can influence outcomes, help improve staff morale and lead to greater engagement of patients in shared decision making. Good service matters. The simple, common-sense approaches presented here, when thoughtfully adapted to the style and pace of a family practice, can help you begin to engage your professional partners and staff in building a service mind-set.