Evolution of Mystery Shopping Health

Patients answer patient satisfaction survey questions based on their perception, and yet there is limited context for the healthcare provider. It leaves one asking the questions - who were they interacting with, what was said, when did it happen, and how capable and reliable was the patient to make those interpretations? So instead of convening a committee to explore the reasons for poor scores, healthcare mystery shopping provides healthcare clients with the research intelligence needed to make real-time improvements.

In an era of value based purchasing with a focus on inpatient stays, I have estimated that over 80% of the lives touched by health systems in this country are not patients at all, but rather family members, visitors, outpatients, and consumers of everything from equipment to Starbucks. By all means make the patient room environment as clean and silent as possible, communicate effectively with the patient, and ensure that they are fully prepared to be discharged, but the emphasis must still be on the patient's perception. Observations, opinions, and ultimately consumer decisions derive from that source.

The elevated importance of patient satisfaction data means that as the data is digested, more and more questions will arise. For instance, a survey will tell you there is a concern with the friendliness of the radiology staff. Instead of creating a broad-brush customer service program for the Radiology Department, the logical next step is to determine how the department is being perceived by end-users, what the department's behavioral weaknesses are, and who on the staff is exhibiting those behaviors.

Together patient satisfaction data and healthcare mystery shopping can begin to focus on meaningful solutions that cause providers to say, "We know from patient satisfaction there is a problem and from mystery shopping we know what that problem is and who is primarily responsible."

While it is recommended that managers look for coaching opportunities by observing their employees in action, expecting them to alter the service culture is less likely since - for the most part - they created the culture. Because this type of research is strictly consumer perception, it provides an unbiased view of a department or organization's culture. This gives managers a third party perspective that increases coaching opportunities.

Types of Healthcare Mystery Shopping

From those early days of healthcare mystery shopping, healthcare provider requests have gotten more creative, more targeted, and more sophisticated. For example, a client may request something as all encompassing as a 24-hour inpatient stay in which the shopper is admitted for a 24-hour period to evaluate the patient experience from registration to discharge. Or shoppers may be asked to call physician offices to make appointments with the intent of determining how long it will be before they can be seen tying the research to more efficient use of resources.

In 2008, healthcare mystery shopping received significant national press when the American Medical Association attempted to take up a position on the practice. What was not as readily reported was the fact that the issue was tabled indefinitely. In fact, it was already the custom of one of the leading providers (prior to the accusation that healthcare mystery shopping was unnecessarily taking up physician time) to utilize what they call process observations. This form of mystery shopping, which is most effective in Emergency Departments, avoids taking up valuable patient time by having a shopper join a patient as a friend as they go through the patient experience.

Two of the most beneficial types of perception research are: 1) shopping the competition, and 2) evaluating individual employees. Call it spying, many do, but it is important to know your competition's culture. For example, what do they believe in and how is it transferred to the patient, and can the anecdotal stories you've heard be verified?

A great deal of value can be derived from conducting evaluations of individual employees. For a number of reasons - cost certainly being a factor - this works best in a departmental environment and gives managers an apples-to-apples comparison of each employee as it pertains to specific standards, i.e., is Cindy more likely than Jeff to greet patients immediately (setting up a coaching opportunity for Jeff)? Or, does Jeff do a great job of cross-selling services and should be commended?

Healthcare mystery shopping also gives managers concrete examples of the specific behavior that "turns patients on." This sets up the perfect opportunity to present to staff the behaviors the organization would like emulated while giving kudos to the employee who displays them.

Quantitative and Qualitative Appeal

Healthcare mystery shopping appeals to managers and administrators whether they are left brained (numbers focused) or right brained (narrative focused). On the one hand, mystery shopping is about story telling. Fred Lee wrote in If Disney Ran Your Hospital, "What seems to be a major component of both loyalty and dissatisfaction are stories. A satisfied person has no story to tell." Stories are important in articulating the who, what, when, where, and how of the patient or consumer experience. The right brain approach to mystery shopping allows clients to clearly discern the difference between a completely satisfactory experience and all the various facets that went into it, and those elements of an experience that triggered displeasure or frustration. At the same time, healthcare mystery shopping is an effective compliance tool. Standards that are specific to the healthcare industry, and therefore can be benchmarked, are mixed with organizationally specific standards to create a quantitative amalgam that can be data spliced in any way necessary. Healthcare mystery shopping primarily answers the following question - How well does your organization perform on the behaviors and processes you told your people are important? In addition, it lets organizations measure those standards against perception-based goals.

The Flexibility of Healthcare Mystery Shopping

Patient satisfaction surveys are, for the most part, static. They are unchanging for a reason. Conversely, healthcare mystery shopping is much more flexible. It can be designed as a program that measures the same standards or processes over time, or studies can be developed to determine exactly what behaviors or processes are being performed.

Healthcare mystery shopping can also be redirected 'on the fly' if the desired objectives are not being met. For example, to their surprise, a physician practice that was asking shoppers to make appointments found out they weren't accepting new patients. Another practice that was evaluating the customer service of their registrars discovered that none of the calls were being answered by a 'live' person. In both instances, the practice put on the brakes until they could fix the issue. One hospital was having shoppers go to their website to look for specific information and then having them request a response. What this uncovered was that the requests were accumulating on a PC that was not being used. This finding allowed the hospital to avoid upsetting hundreds of consumers who felt they were being rudely ignored.

How does one know if a service initiative is really working? Healthcare mystery shopping is an excellent complement to any service initiative. It can be directed in such a way that it provides real time verification that the initiative is being effective. Anything from a discharge process to valet service can be shopped at various times to ensure that the initiative's message was received and implemented.

Flexibility does not, however, extend to internal programs. Sometimes in the name of saving money, healthcare providers will launch a do-it-yourself program. They attempt to get employees or volunteers to perform the same function that professional healthcare mystery shopping firms do. This rarely if ever works for any duration for obvious reasons. Insiders have internal biases and, despite their best intentions, are no longer able to be objective. The other reason this is not effective is that employees (and even volunteers) can think of a million things they should be doing or would rather be doing. And the lack of staying power for a do-it-yourself program puts a tremendous burden on the manager assigned to administer the task.

What Clients are Looking For

Hospitals, health systems and physician practices seek out healthcare mystery shopping vendors for a number of reasons. In some cases, they want to validate "good news." For example, one health system client entered into a long-term relationship with the primary goal of proving that their services were superior to the competition that was also shopped. A recent wayfinding study of over 300 'shops' conducted for a large hospital on the east coast concluded that less than 76% of their employees received a top box score of five for greeting consumers with a smile. This finding was indicative of a culture that was not treating consumers in 'a personal and memorable way.' However, healthcare mystery shopping afforded them the advantage of validating their original concern, isolating where this concern is most prevalent, and using the shopper's language to convey to staff why greeting people was critically important to overall perception. Much like satisfaction surveys, healthcare mystery shopping is able to monitor improvement over time, but with the added benefit of story telling to pinpoint issues. It can also be instrumental in determining the specific nature of the concern and identifying where weaknesses exist.

A healthcare mystery shopping executive, who is undergoing therapy for breast cancer, wrote in a blog recently, "What matters to healthcare organizations are things like how many steps it takes to check a patient in, scripted greetings for frontline employees, record keeping for correct billing, and clinical training for new safety measures. However, as a patient, I notice if the person checking me in for chemo is smiling and greets me because she cares, not if she delivers a scripted sentence. Next, I notice if the nurses in the chemo area are working as a team and greet me personally (they should know me after two months). But what is most important to me is whether or not the clinical staff is aligned with my recovery goals."

While this executive may be more attuned to her surroundings than most patients and able to articulate what it means to her, the goal for any healthcare mystery-shopping program is to use the shopper's heightened sense of awareness and their ability to effectively communicate their experiences in a way that is clear and concise.