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Is a "mystery shopper" lurking in your waiting room?


Spies, masquerading as patients, may be snooping around your practice. You could learn a lot from them.


Is a "mystery shopper" lurking in your waiting room?

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Choose article section... Good performance can get even better A shopping excursion causes rancor Take the mystery out of selecting a shopping service If you want to evaluate your practice

Spies, masquerading as patients, may be snooping around your practice. You could learn a lot from them.

By Deborah Borfitz

For six months, ob/gyn John E. Drake and his colleagues could never be sure whether a new patient—or even an established one returning for a follow-up—was doubling as a medical spy. The Northeast OB-GYN doctors knew that a troupe of specially trained "mystery shoppers," and a few of their friends, had been visiting the office periodically to assess the doctors' interpersonal skills.

Checking out how this group of Fort Wayne, IN, doctors went about their business was just one of the appointed tasks for these undercover shoppers. They also assessed how well nurses nursed and how knowledgeable and chipper front-office staff seemed to be.

The faux patients, who worked for Kevin Billingsley, a specialist in health care "mystery shopping," gave doctors stellar reviews on their friendliness and willingness to listen, which can make even a five-minute visit feel more like a pampering half-hour. The staff also scored well in this department. But telephone wait times and the automated answering system were sources of frustration. And virtually no one in the office, either on the phone or in person, bothered with the courtesy of self-identification.

All this may not sound like a big deal, but it should, says Tami Furniss, business manager for the practice. If patients aren't satisfied with customer service, she says, they'll leave—perhaps for a more friendly practice just down the street.

Mystery shopping has helped some practices improve patient callback procedures, establish a more confidential sign-in policy, and institute a more professional dress code for physicians.

Occasionally, a mystery patient's findings convince doctors that an employee needs to go. Depending on the shoppers' level of expertise, their insights may even help reduce medical errors and malpractice risks and enhance patient safety.

Doctors who have paid to be critiqued by a mystery shopper say it can be enormously helpful—or an exercise in futility. Of course, a lot depends on whether they agreed in advance to be shopped. Groups aren't the only ones hiring mystery shoppers to visit doctors; hospitals have used them, too.

But even when doctors are the ones behind the idea, mystery shopping has its limitations. "It's one person's personal experience on one day in the life of an organization," says Houston-based consultant Diane Peterson. "Still, it seems to be motivational, spurring employees to action where patient satisfaction surveys haven't."

Interpersonal skills are invariably the biggest item on the mystery shopper's mental checklist. "Physicians, for the most part, have no idea why some patients are dissatisfied," says San Diego-based consultant Meryl D. Luallin. "And, indeed, doctors often aren't the offending parties. It may instead be the unthinking receptionist who answers the phone, 'Doctor's office!' instead of 'Good morning, Dr. Jones' office. This is Sheila. May I help you?' "

The behavioral assessment looks at things like body language, demeanor, and how pleasant employees make the waiting process, says John O'Malley, president of Birmingham, AL-based Strategic Visions.

"A lot of doctors would benefit from some training in how to be a little bit more compassionate and understanding, and I think that these kinds of programs provide that," says one recently shopped physician, adding that his is the "minority opinion" within his group. "Many in my profession look at their partners and the competition and say, 'They're the dispassionate and insensitive individuals, not me.' That attitude is a big barrier to improving your practice."

Cost is another issue: Per-doctor evaluations can run as much as $1,250. Billingsley offers 100 shops for $10,000, half on the phone and half in person. Customer Perspectives in Hooksett, NH, charges $120 to $150 per in-person shop and $25 to $30 for each shop by telephone.

Mystery shopping was never meant to be a "spy mission," consultants say. But, in truth, it operates much like one. "There has to be a confederate," says Raleigh, NC-based consultant Suzanne Boswell, author of The Mystery Patient's Guide to Gaining & Retaining Patients (PennWell Books, 1997). In larger organizations, that's typically a physician who helps work out the premise for the visit and the kinds of symptoms the "patient" should exhibit. Luallin says she'd prefer to skip the cloak-and-dagger approach and do a "shadow assessment" instead—spending the day going in and out of the exam room with a doctor. "But it makes some doctors uncomfortable," says Luallin.

Here are two practices' experiences with mystery shoppers.

Good performance can get even better

The six doctors and the staff at Northeast OB-GYN knew they were going under the microscope; they just didn't know precisely when, or who would be scrutinizing them. "There are plenty of other gynecologists in Fort Wayne, and the competition is getting tougher. We want to know if our practice is doing the best it can in the eyes of the public," explains Drake. "Even if you're the best doctor on the planet, your practice may aggravate patients."

The idea was not so much for the doctors to examine themselves, as to learn how their employees were affecting the practice's bottom line, says Billingsley. Customer dissatisfaction is "rarely about the doctor," with whom patients generally spend the least time, he says. "It's more about how patients are treated up front."

The six-month, $10,000 study encompassed 200 telephone mystery shops (which included 50 to another Fort Wayne practice), as well as 40 in-person mystery shops of Northeast OB-GYN and 10 of the competition. Few of the office visits went all the way to the doctor. Among those that did, the shopper was either a real patient or with someone who was. "It's not our policy to fake an injury or medical condition in person," says Billingsley.

The telephone shoppers would call with a made-up story about, for example, how they were new to the area and looking for an ob/gyn, or needed advice about what to tell their 68-year-old neighbor who had just discovered a lump in her breast. One male shopper posed as a single dad seeking guidance on when to take his developing daughter in for her first gynecological exam. The idea, says Furniss, is to assess employees' knowledge and promotion of the practice, how well they abide by office policies to state their name and offer an appointment, and how "up and chipper" they sound when answering inquiries.

Results of the telephone shops rolled in monthly in the form of a one-page spreadsheet containing the name and score of each front desk worker. A more in-depth narrative on individual encounters, including opinions and recommendations by the mystery shopper, was presented in a separate report within two business days. Overall, front-line staff did a good job of listening empathically and offering assistance in a friendly tone, Furniss says. But many of them did less well when it came to identifying themselves, speaking slowly and clearly, getting permission before putting patients on hold, and then not keeping them on hold too long. And most staffers, when asked, didn't know the practice's Web address.

Simply showing employees their patient perception scores was enough to elicit some immediate changes without much fuss, says Furniss. She also posted the practice's Web address near the telephone, and she and Drake started reminding staff to wear their name tags. "We don't use mystery shopping to terminate employees or write them up, and we don't use it for raises. It's just a means of improving the practice," says Furniss.

The in-person mystery shopping tours were more difficult to score because they often looked at multiple people and processes. Typically, shoppers walked through the door unannounced, observing what went on in the lobby and asking the staff at the front desk questions about the doctor and practice.

The first round of results was presented to the doctors midway through the study. "The scores weren't bad, especially on the telephone," says Billingsley. "They outscored the competition." At least one mystery shopper—a patient of a competitor—chose to pick up her chart and permanently move to Northeast OB-GYN. But the shopping showed that the practice could better satisfy patients by providing a more private space for them to view their medical files, cutting telephone wait time, and adding an option to the telephone answering system for simply asking a question.

Once that was accomplished, says Billingsley, the doctors could begin to look at how to enhance customer service to attract patients in the first place. For instance, callers requesting an appointment with a doctor no longer with the group could be regarded as an opportunity to tout the credentials of the current partners. Or those callers could be directed to a promotional Web site for more information.

There are also a few policy issues that might bear re-examining, says Billingsley. For example, a few of the mystery shoppers were put off by the front desk's unwillingness to transfer telephone calls for basic clinical advice to a nurse unless the caller was an existing patient. Similarly, the practice should be more forthcoming with nonclinical information when it's dealing with potential new patients. Furniss says that the study was worth every penny spent and would be a valuable investment for any practice. "It's a good learning tool to see how you measure up."

A shopping excursion causes rancor

Sutter Gould Medical Foundation in Modesto, CA, gave mystery shopping a trial run two years ago. First, the then-110-doctor group tried the method on two providers whose patient satisfaction scores were "surprisingly" low, says FP Roger K. Howe, then Gould's vice president of medical affairs.

The two doctors agreed to invest $1,000 apiece to be mystery-shopped by consultant Meryl D. Luallin. "Part of the reason they were willing to participate was that they were perplexed, too," says Howe. "Both are personable, caring individuals." As it turned out, nothing "very substantial" was revealed that might explain the doctors' satisfaction ratings.

Nevertheless, the group's medical executive committee decided to adopt mystery shopping as an educational tool for new doctors whose patients were "less than happy." None of the three new doctors at Gould who were later shopped at practice expense—a dermatologist, ophthalmologist, and internist—knew about it in advance. There was a "mixed bag" of reactions, says Howe. "Attitude presaged the outcomes."

The dermatologist, indignant that she had been spied on, refused to meet with Luallin afterward to go over her written evaluation. She later left the practice. "The ophthalmologist said he had been having a bad day when the mystery shopper visited, accepted the criticism with relatively poor grace, and later resigned from Gould," says Howe. "The internist received the criticism in the spirit in which it was intended, and her enjoyment of her practice improved."

The changes implemented by the internist, Jean Macarubbo, were seemingly minor. "The survey just opened my eyes to things I already knew were happening but hadn't bothered to correct," she admits. It was her habit, for instance, to sit with her back to patients while doing paperwork. She would also, on occasion, conduct a brief exam during "get acquainted" visits with new patients. And when she discussed treatment options, she tended to lapse into medical terminology that a layman probably wouldn't understand.

Today, Macarubbo makes it a point to position herself toward patients as much as possible, get their permission before doing unexpected exams, and tone down the jargon. She says that she would willingly pay to give her bedside manner another checkup to ensure these improvements are maintained and any other needed ones are made.

The fee will have to come out of her pocket. While Gould continues to work with Luallin on customer service issues, the mystery patient program has been suspended because the results didn't justify its continuance, says Howe. Overall, satisfaction scores for the five doctors showed no change pre- and post-shop. Part of the problem is that the practice has yet to find a reliable satisfaction survey tool.

Howe still believes in the potential of mystery shopping to identify problems with doctors and, especially, with clinical processes in the office. Based on Luallin's mystery patient engagement at Gould, the practice instituted several operational changes. For example, a canned customer service orientation program is now more patient-focused and specific to what happens in a medical practice.

But when it comes to making changes in physician behavior, Howe says, the devil is in the details. "Hiring mystery patients is expensive enough that you need to put some thought into how to apply it."

The author is a freelance writer based in Vero Beach, FL.

Take the mystery out of selecting a shopping service

John O'Malley, president of Birmingham, AL-based Strategic Visions, advises doctors to seek a mystery-patient service that offers:

An employee-friendly process. The focus should be on the procedures and processes during the actual encounter with patients. Informing all employees up front that mystery patient surveys are part of your patient satisfaction program is critical to the effort's success.

The right mystery patients. Surveyors' age, sex, and ethnicity should match those of the patient population. Shoppers should have a solid understanding of how health care ought to be delivered. This includes whether the service provided was appropriate, what service was lacking, and how best to deliver a specific service.

Some consultants believe that people with a professional health care background may give themselves away by their vocabulary and might overly identify with providers. The most objective shoppers, say consultants, don't come from the profession.

But O'Malley disagrees. He says that professional surveyors have no difficulty being objective, and they're trained to use a nonmedical demeanor and vocabulary. He recommends using a health care professional who knows how a doctor's office is supposed to run—not someone who just observes what's being done.

A detailed report. This is a must. An additional video report should be an option, because it will enable you to review the report with the entire staff at a meeting.

Solid advice. The report should include realistic suggestions and approaches for improving areas of concern, as well as overall service.

Employee training. Ideally, a mystery shopping company should provide on-site customer service and patient satisfaction training and, if it's needed, should help create a new customer service program.

If you want to evaluate your practice

These companies and individuals provide mystery shopping for physician practices:

Joyce Brazino, RN
Philadelphia, 215-985-0860

Customer Perspectives
Hooksett, NH, 603-647-1300
Contact: Judi Hess

Healthcare Impression Management Services
Suzanne Boswell Presentations
Raleigh, NC, 919-845-4189
Contact: Suzanne Boswell

Perception Strategies
Indianapolis, 317-594-8642
Contact: Kevin Billingsley

Perceptive Market Research
Gainesville, FL, 800-749-6760, ext. 4012
Contact: Ken Lyons
(For doctors' offices, telephone shops only)

D. Peterson and Associates
Houston, 713-795-5800
Contact: Diane Peterson

Strategic Visions
Birmingham, AL, 205-995-8495
Contact: John O'Malley

San Diego, 619-283-8988
Contact: Meryl Luallin


Deborah Borfitz. Is a "mystery shopper" lurking in your waiting room?. Medical Economics 2001;10:63.

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