Trust and Loyalty
You and your office have a contract with your patients. You expect certain things from them and they expect certain things in return. Ethical relationships are built on trust that each will honor their part of the contract. Sometimes relationships continue in form despite their being imbalanced or even when based on duplicity. Patients, for example, may tall their friends about disappointed expectations with their dentist—even when the expectation is unrealistic or they have not told the office about their dissatisfaction. Offices may subconsciously disrespect patients in the name of efficiency or superior dental knowledge. It is not the stability of patient-dentist relationships that counts: it is the quality.
Gather data using a Patient Satisfaction Survey instrument that appears at the end of this Block.
The best way to find out what patients think about their experience in your office is to ask them. But, of course, some approaches are nice but not so helpful replies. To help get good feedback, you can use the attached Patient Satisfaction Survey form.
The form should be used anonymously and precautions for protecting patient identity are valuable. For example, a covered box for returning the forms or even the opportunity to complete the form on the Internet would help. The reasons given for the survey are also important. Use of the results to improvement the practice should be stressed. You may also want to mention that the form has been approved by the ADA [which, in fact, it has] or is being used by many dentists across the country [which we hope will be the case]. Obviously, any abuse of confidentiality is a deal breaker for that patient and all others.
It matters how the surveys are distributed. You want an honest, representative sample of your patients. If you only give it to your favorite patients, you are in effect lying to yourself. A rolling block sampling plan works best. On a given week, all Monday morning patients get the survey with a strong emphasis on getting 100% returns. Small blocks of 100% compliance are much less biased than large samples of selective compliance. On Tuesday, all afternoon patients are queried, Wednesday morning, Thursday afternoon, and Friday morning. Of course, if you are open fewer days during the week, those times will be skipped. Wait three weeks and then repeat the process, but start with Monday afternoon, Tuesday morning, etc. Wait three week and repeat, etc. This approach minimizes bias due to targeting patients and provides a nice, even sampling across days of the week, times of the year, and other potentially confounding factors.
How many survey forms are necessary? A hundred would be a good start. And it is suggested below that periods of gathering information, then stopping to analyze results and make changes, then sampling again work very well. The better the office is, the larger the needed sample. This may seem paradoxical, but it is not. The best offices will have momentously positive responses that suggest no needed changes. They will have to ask a lot of patients before they find an actionable prospect for improvement. The offices that are just starting on their path to more ethical patient relationships will find chances on many survey forms.
The Patient Satisfaction Survey form is available online using the buttom immediately below. It is available as a PDF document, which can be printed or copied into a new text document. If the latter it is possible to customize the form. For example, the name of the dentist or the office can be added and other personalizing touches would be welcome. The office may wish to modify some questions or add new ones. This is fine, but it is urged that the existing questions be tried first because they are based on the literature regarding customer satisfaction. Remember the “one-page rule.”
- A staff member should be designated to review all forms returned each day. If there is a need for immediate action (the toilet in the bathroom is broken), respond in a timely fashion. But avoid the temptation to respond reflexively to a single negative response—you are looking for trends.
- A staff member should be designated to summarize the set of responses from each sampling period.
- The Patient Satisfaction Survey form asks about both what the patient expected and whether they got it. The scoring combines these two dimensions so there is a single number for each question. The table below shows how to combine the importance and performance side of each question into a single value. For example, delivering on an important aspect of care is worth 4 points to the good. But is it five times as bad to disappoint a patient on something they feel is vital.
|Vital|| 8|| 6|| -20|
|Important|| 6|| 4|| -12|
|Nice|| 2|| 0|| -4|
- With all due respect to the merchants of sizzle on the CE circuit, they are wrong. One cannot make up for failing to meet patients’ needs by vastly exceeding them in some other area. Research shows that a well satisfied customer tells one friend and a disappointed one tells seven. The scoring table gives disproportionate weight to the vital needs of patients and to failing to meet their expectations. There is relatively little weight attached to nice features of the practice and to exceeding expectations.
- A total score per patient and an average score for the office for each particular survey period can also be calculated. When the surveys have been scored, they should be arranged in order by score with the lowest scores on top.
- The survey results for each sampling should be discussed by the entire office staff. Patterns are more important than isolated results. The most important focus for the analysis is trends at the negative end of the score scale. They direct attention to the greatest opportunities for improvement.
- Make a list of the most important problems—the items that tend to have the lowest scores. These concerns should be anchored by reference to your practice philosophy and your office code and standards. The whole office team should review these documents. It would also be valuable to review the Office Climate Inventory exercise C4 from the previous block. Avoid ad hoc reactions to isolated patient concerns. Changes should be driven by your ethical standards. Differences between what you want your office to accomplish and the Disappointed ratings of patients are called your “office ethical adequacy gap.”
- Offices that are ethically mature will have few or scattered patient concerns. (Everyone has an off day now and then, including patients.) Striving for excellence should be attempted after problems are fixed and not as a means of compensating for problems that remain uncorrected. Excellence should be guided by the practice philosophy. What are the essential elements of the practice? These were identified in Block A in the Practice Values Survey exercise. Because you have said these are critical to your office philosophy, you will want to see if what matters most to you is matched by positive patient responses. For each of the key factors you identified determine whether patients agree with you by rating these factors as Vital. Then look to see whether patients feel that the office is exceeding expectations on the factors that are most important to you. Differences between meeting and exceeding patient expectations on what matters most to the office are called your “office ethical excellence gap.”
- The two questions about length of time patients have been in the community and in the practice are designed to show differences between established and new patients. The responses of long-term patients in the practice get special attention. Any problems here signal that something is slipping. Patients who are new to the community will have the freshest eyes, and their responses should be given careful attention. Patients who have been in the community for some time but are new to the office might be expected to pay more critical attention to the features of the office since they either do not have a regular dentist or are switching dentists.
- The question about ethical standards of the practice is exactly the item that has appeared on the Gallop Poll survey of professionals for many years. It may be of more general interest than it is of diagnostic value. Over the past 25 years, the percentage of the general adult population that rates dentists as “very high” or “high” on ethical standards has increased from 52% in 1981 to 62% in 2006. The Chicken Little rhetoric of some in the profession comes from the fact that new professions, such as nurses and firemen, have been added to the survey. Because these are high-trust professions, the rank of dentistry has gone down while the level of trust has actually gone up. Dentists should expect to see the proportion of “agree” and “strongly agree” responses in their practices to be in the high 90% range since patients have chosen the office and there is a positive bias of completing the form while sitting in the office they have chosen.
Closing the Gap
The “office ethical adequacy gap” should be addressed first. Resist the temptation to work in two directions at the same time because that will lead to confusion. There is always time to advance excellence; there is very little time to achieve adequacy.
The following steps are useful in addressing performance gaps:
- First, make certain that each pattern of problem is relevant to your practice philosophy and that it is covered in your Office Code and Standards. You may have gaps because you overlooked or assumed something that matters to your patients. Add whatever is needed to the Office Code and Standards and to your existing office manual.
- Next, explore the office routines, scheduling, assignments of responsibility, and reward structure that may be interfering with meeting patient’s expectations that are important to your office. Change the office manual to remove barriers to meeting these needs.
- Set a goal. The only way to know whether the adjustments you have made have been effective is to compare patient responses before and after the changes. A new round of surveys will be needed, and the office should agree on the types of ratings they expect. Often it is more helpful to express the goal as no or a small number of “disappointed” ratings rather than an average that can mask lingering problems.
- A note on the psychology of self-improvement: All experts would not agree with the approach suggested here. Some feel that changes can be made and even sustained by will power. Promising to try harder or even “reaching an understanding that things will change” are common approaches to workplace improvement, as well as weight loss and marriages that are having difficulties. Good intentions that are not supported by structural changes in policy and routine tend to fade quickly. In extreme cases, any member of the office may be ill-fitted for the philosophy of the practice, and, following appropriate attempts at adjustments, a personnel change may be the best approach. That is a structural change.
For ethically mature offices, the four steps for addressing “adequacy gaps” can also be used to promote excellence. In this case, it would be unusual to make large modifications in the office Statement of Philosophy or Code, or even in the office manual since these are the touchstones that are driving excellence. When setting a goal for excellence, the proportion of “exceeds” or “meets” ratings is the appropriate outcome, in contrast to number of “disappointed” ratings. (It is expected that there will be no “disappointed” ratings since those were taken care of in previous cycles with this system.)
This is also the place to consider modifying the Patient Satisfaction Survey instrument. It may be the case that the six standard items that comprise the basic survey fail to register the unique ethical strengths of your practice. The items that are already received strong ratings from patients can now be replaced by special items constructed to test for special goals that come from the Practice Philosophy. (An alternative is to use multiple forms that add new items to all forms and use patient samples for standard, already well-covered items. In this system, the new items appear on every form and two or three established items would show up on every second or every third survey form.)
- Obtain another sample of Patient Satisfaction survey.
Wait several months after agreeing on the measures that should be taken to address identified adequacy or excellence gaps in order to allow the changes that have been made in office routine to become habit. Then take a new sample of patient satisfaction.
The process can be repeated as often as it is useful in prompting improvements. Each cycle can be expected to require about six months to complete.
- Maister, D. H. (1993). Managing the Professional Service Firm. ISBN 0-02-919782-1.
- Zeithaml, V. A., Parasuraman, A., and Berry, L. L. (1990), Delivering Quality Service: Balancing Customer Perceptions and Expectations.ISBN 0-02-935701-2.
- The Agency for Healthcare Research and Quality maintains a collection of measures of quality in medicine. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) is a standardized instrument very similar to the Patient Satisfaction Survey form presented here. It is required of physicians and surgeons who receive Medicare reimbursement.
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