Does this sound familiar? You start an ambitious home improvement project on Sunday afternoon but can't quite finish it in the three-hour window you gave yourself. Undaunted, you leave all your materials out in full view, planning to return to the project as soon as you can. Over the next few days, that ladder and toolbox become annoying and obtrusive, but they're not enough to convince you to finish the project. Six months later, they're part of your home's permanent landscape.

Psychologists call this phenomenon “habituation,” and it's not limited to homes. It can also happen in busy family medicine practices. Usually the unsightly details in medical practices are small, and thus easy to overlook by busy physicians and staff members focused on patient care.

However, patients are looking. Small details and first impressions have the potential to create a powerful set of assumptions. If patients see something askew or neglected, it may plant seeds of doubt in their minds about the practice's quality of care.

The observations in this article are based on data from the TransforMED national demonstration project (for more information, see “TransforMED Tries to Rebuild Family Medicine,” FPM, May 2007). Practice facilitators and research staff members visited dozens of practices across the country and noted some of the most commonly overlooked details, as well as some of the easy and inexpensive ways practices create a positive first impression.

Let's take a walk around your practice and see it with fresh eyes. We'll start with your patients' first stop: the waiting room.

1. Enter your waiting room

Patients don't expect a waiting room to look like the lobby of a four-star hotel. However, they do notice the following:

• Mounds of messy, outdated magazines or a magazine collection that's dominated by one specific topic (e.g., the past five years of Field and Stream).

• Dirty, scuffed or ripped furniture. Most practices can't afford to replace their furniture, but a chair with a stuffing rupture requires an immediate “aesthetic procedure.”

• Anemic-looking plants or silk plants covered with dust.

• No visible wastebasket. Most patients don't mean to litter, but their used tissues and paper cups still end up under waiting room chairs. Unfortunately, this reflects poorly on the practice.

• A preponderance of literature on either the latest cosmetic service the practice is offering or the latest pharmaceutical company cure, crowding out the less glossy but more objective patient-education materials.

• Anything on the wall that is crooked – pictures, posters or signs.

• Extra-loud TVs or background music.

Practice Tip: In some TransforMED practices, a staff member walks through the waiting room every few hours to straighten magazines, pick up trash or run a sweeper. Chair arms, children's toys and other high-touch areas are wiped down daily with antiseptic cloths. Another practice created a patient library of books and magazines to which staff and patients contribute.

2. Approach your front desk

This is where all the action happens, and it's the place that can make or break a practice's reputation. There are countless articles on the importance of friendly front-desk staff, but the appearance of the front-desk area itself also sets the tone. Patients can be turned off by the following:

• Excessive signage, particularly if the messages are authoritative toward patients (e.g., “co-payments due now” or “stand back five feet”).

• Sloppy signs. A taped piece of paper with careless lettering undermines the importance of any message. Creative staff members using computer graphics and a plastic page sleeve can improve signage at very low cost.

• The window effect. Many practices have a glass wall that separates the patient from the front-desk staff, and while its purpose is patient privacy, patients don't know that. They see an enormous barrier and staff members who often look annoyed at having to open and shut the window. In this scenario, the added responsibility is on the front-desk employees to show the proper demeanor. They need to welcome each patient with a smile and leave the window open until the patient walks away.

• Desktop clutter. Many practices are choosing to open the front desk by eliminating the traditional glass wall. This setup is friendlier, but it puts added responsibility on staff members to minimize clutter in their workspace, especially food and beverages. The front desk should echo what patients hope to see on the clinical side. It should be clean, organized and hygienic.

• Loud conversations among staff members. Social talk can be healthy and build staff camaraderie. However, gossip about last night's “American Idol” episode can easily float from the front desk to the waiting room, as can questions or comments patients really shouldn't hear. Habituation can be auditory as well as visual.

Practice Tip: One practice solved its signage dilemma by posting a bulletin board next to the window. The board accommodates the necessary signage but also allows room for “friendlier” announcements, and even photos.

3. Head down the back hall

They are the circulatory system of a practice, but some back halls suffer from blockage:

• Boxes stacked along walls … permanently. There are times when the hallway must serve as temporary storage, but be mindful of how long the boxes sit and how they are labeled. It is disconcerting for a patient to see a box marked “DECEASED.”

• Visible and prolonged hallway conversations with drug reps. Patients can put two and two together when they pass the physician chatting with a drug rep and then wait 20 minutes in the exam room.

Back halls can also have these problems:

• Untidy views. As patients stroll to their exam room, what do they see? The cluttered back side of a front desk? A messy break room? Chaos in the clinical station? Fair or not, many patients may find themselves wondering if the untidiness represents larger problems in the practice.

• Dirty restrooms. Enough said.

• Odious smells. You don't want patients wondering, “What's that smell?” – unless it's a pleasant one. The good news is that olfactory enhancement can do more than provide relief from yesterday's burnt popcorn; there is evidence that aromatherapy may actually foster relaxation.¹

Practice Tip: One practice used inexpensive, plug-in air fresheners to produce pleasing scents throughout the practice. For an investment of $8 a month, the practice received positive patient feedback almost daily. However, what smells nice to some patients might irritate others, especially those with allergies, so ask for feedback from your staff and your patients.

4. Sit in an exam room

Patients probably spend the most time in the exam room. What might they experience there?

• Signs that you are behind the times. When patients see flu shot notices with expired dates or last year's calendar, they can't help but wonder about timeliness and attention to detail.

• Tired artwork and wall colors. Several TransforMED practices enlisted friends and patients to paint engaging murals in exam rooms. If you lack the time or talent to pull off a mural, don't worry. Repainting the room in a pleasing color can be renewing.

• Unprofessional physician and staff appearance. Patients notice details like untucked shirts and flip-flops. Dictating a dress code can be a thorny issue, but many practices get around it by promoting a unified look of matching scrubs or logo shirts. Physicians should remember that staff look to them to set an example.

Practice Tip: One TransforMED practice hired a patient to plant a beautiful garden out front and used the fresh-cut flowers to grace exam rooms and the waiting room.

Take a walk

Take a lead from the business world and try a technique known as “management by walking around.” Managers typically use this technique to observe and better understand staff they supervise. You can use this technique to understand your practice's first impression. Everyday routines such as entering through the back door can result in habituation to the rest of the practice. Try coming in through the front door and seeing things through the eyes of your patients. Better yet, enlist the assistance of trusted patients to simply walk around with you and notice the things you probably don't anymore.