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Healthier Practice, Healthier Patients
Everyone benefits when patients keep coming back.
BY WILLIAM B. RABOURN, JR.

While refractive surgery practices may be more concerned with sustaining a high rate of growth because of the inherent number of "one-time buyers," a general ophthalmology practice, even one with a healthy growth rate in excess of 10%, must attend to retaining current patients if it is to experience net growth. In general, retention rate stands as a crucial benchmark of the financial health and stability of a practice.

It goes without saying that the quality of care you deliver impacts your patients' health, and that maintaining a high rate of retention impacts the financial health of your practice. The relationship between retention rate and quality of care may not be so obvious, however. We expect the delivery of high-quality care to favorably influence retention rate, but those non-clinical actions you take to improve retention — can they improve both your practice's bottom line and patient outcomes?

While there is little objective evidence that a physician's patient-centered style actually improves outcomes, research confirms that it does positively influence patients' health status and compliance with treatment. On the other side of the coin, a negative perception of a physician's interpersonal style has been associated with psychological factors that negatively impact immune function and mortality. It is time to stop looking at retention rate as a measure of only the practice's health, and begin to appreciate its influence on patient health. The same interpersonal relationships you forge that keep them coming back to your practice may also lead to better outcomes for these patients.

Patients Vote with Their Feet

Patients may express their dissatisfaction with an aspect of their care by complaining, but far more often they vote with their feet and their pocketbooks. You and your staff may never know why a patient moves on to another practice, which makes it all the more vital to develop an awareness of factors that contribute to achieving and maintaining a healthy retention rate. The delivery of high-quality care remains, of course, sine qua non, but why does the quality of the care delivered sometimes seem out of sync with a practice's rate of retention? We all know of at least one practitioner who manages to maintain a sizeable practice of loyal patients despite what peers would consider comparatively low investment in new technology or somewhat less-than-outstanding clinical skills. Rate of retention, then, may not always be a valid indication of the quality of care delivered by a practice — depending upon how "quality" is perceived.

"Good" Doc / "Bad" Doc

We know intuitively that patients who are satisfied with the quality of the care they receive are more likely to stay with your practice. However, the factors that generate and maintain patient loyalty to your practice may have less to do with your clinical expertise than one would think, because the actual quality of the care you deliver may differ significantly from patients' perception of the quality of care they receive. Whether you are "good" or "bad" in your patients' eyes is, of course, a highly subjective judgment. Research indicates that patients evaluate their physicians based on perceived:

►clinical proficiency
►sensitivity to the feelings of patients
►presence or absence of positive personality traits
►ability to adapt to the patient's needs (patient-centered vs. self-centered)
►accessibility (devoting sufficient time to consultations and "short notice" availability)
►communication style (providing information and explanations appropriate to a patient's needs)
►honesty and candor
►disinterest in money (personal dedication as a healer).

This last factor is particularly important in detecting a "bad" doctor, with financial motivation seen as more significant than lack of skill or experience. Surprisingly, the professional qualities that physicians themselves may associate with high-quality medical care, such as teaching appointments at academic medical centers and participation in research, are not consistently valued by patients.

Study after study demonstrates that patients want their physicians to be highly skilled clinicians who provide humane personal care. They attach more importance to being kept well-informed and being able to participate in decision-making. First and foremost, patients want the physician to respect their autonomy. They clearly do not want to deal with an impatient or distracted physician, and will seek out doctors who offer relaxed, unhurried communication.

The evidence clearly indicates that patients want a physician who employs a patient-centered approach to practice. Under the circumstances, a physician's failure to recognize patients' subjective experience of their condition and implement this patient-centered approach seriously erodes patient satisfaction and perception of quality. This perception can become particularly important in the event of a "bad" clinical result; how well or badly you have treated your patient in the non-clinical arena does influence decisions to pursue or not pursue litigation.

Managing Expectations

The challenge you face is to bring patients' perception of quality into closer alignment with actual quality by developing the type of relationship that maintains the continuity of care and, in turn, enhances the quality of outcomes.

As a practical matter, how is this to be accomplished?

Surgical expectations are higher than ever. Begin by taking a proactive stance toward managing your patients' expectations. In the past, patient expectations were shaped largely by physicians and other healthcare providers. Today, non-authoritative sources, including the media in general and the Internet in particular, drive patient expectations. Increasingly, this information is based on notoriously unreliable reports of single-study results. The resulting expectations exert considerable force on practice patterns, driving patients' demands that physicians make "contrary to evidence" clinical decisions that tend (at least in the short term) to enhance rates of retention but may negatively impact quality of care. Research suggests that a physician's perception of patients' expectations is a strong predictor of prescribing behavior, for example.

Providing patients with appropriate educational materials can counter at least some of the media influence that over-promises and makes you appear to under-deliver. To be effective for this purpose, however, that information must be evidence-based, as opposed to totally marketing-oriented. Carefully evaluate the orientation of your materials for a proper balance between education and marketing; the opinions of a small, informal focus group may be useful for this purpose. If new materials are required, look for a vendor offering professionally written copy to which you can add your own personal touch. Providing cataract patients with a system displaying educational eye animations that tells them what to expect from their surgery results in a significant increase in their understanding of and satisfaction with the experience. Research suggests that the reported decrease in anxiety may be a factor in these patients' improved perception of the quality of outcome. 

However important evidence-based materials may be, they are only one aspect of a culture of patient-centered communication you should be creating within your practice. When patients "vote with their feet," the practice's retention rate falls, and the resulting discontinuity in treatment negatively impacts quality of care. In this case, perceived quality influences actual quality.

Patients' Perceptions

The development and management of patients' perceptions of quality begins long before their first contact with the physician. The wider practice team, in particular your receptionist, often crafts a new patient's perception of the quality of care they can expect to receive.

Ease of telephone communication and appointment scheduling, as well as the length of time spent in the reception area waiting to see you, will influence perception of quality. The receptionist is the person in your practice most likely to be on a mutual first-name basis with the patient and often has the power to streamline waiting times by assessing urgency. Your technicians and counselors should be skilled in delivering and discussing the evidence-based educational information and materials previously mentioned. One positive experience when consulting an unfamiliar physician can motivate a patient to develop a continuing relationship for care in the future.

Most patients attach a high value to ease of access to the physician and the services of the practice. Patients with very busy schedules are likely to value quick access and to perceive a continuing relationship with a physician as less important. Encouraging continuity of care by accommodating their needs for access can exert positive influence on outcomes for these patients by opening the door to preventive treatment and more effective coordination of care.

Perceptions are Contagious

Patients' perceptions of quality impact not only retention, but word-of-mouth and recommendations as well. A high level of satisfaction with the working style of the doctor and practice correlates closely with a patient's willingness to recommend that doctor to friends. This willingness is particularly important to refractive practices treating "one-time buyers" of procedures. Data collected from a focus group I recently conducted suggests that, all other things being equal, a recommendation from a friend who has had LASIK is worth nearly five times as much to a practice's revenue than mere "word-of-mouth" when a prospective patient selects a LASIK surgeon in a competitive market.

Every Patient is Special

In short, enhancing your practice's retention and growth rates may be as easy (and as difficult) as treating each patient as an individual, not as just another patient. Simply remembering patients' names and demonstrating that you remember them exerts a powerful influence on their perception of the quality of care they receive — and that perception and resulting loyalty to the practice translates into better health for both the patient and the practice. 

Bill Rabourn is a managing principal of Medical Consulting Group, LLC, in Springfield, Mo. (www.medcgroup.com). PatientBuilder.com is a wholly-owned subsidiary of Medical Consulting Group.