Archive for March, 2010

You expect complaints in any business, healthcare related or not. But how you handle the complaints, which are really about service breakdowns, can make or break a medical practice’s relationship with its patients. Just because complaint rates are low doesn’t mean it’s time to celebrate. Medical practice employees then become tempted to send dissatisfied patients away, rather than admitting to a service failure.

Rewarding exceptional solutions to problems is the way to ensure a long-lasting patient/practice relationship. “Service Recovery” means fixing service breakdowns. For instance:

• When patients have a billing or business problem, they want you to help them fix it. They do not want to be transferred to someone else to explain their problem all over again. They want you to take responsibility.
• When a patient has a non-practice problem, such as a flat tire in your parking lot, they expect you to do something to help, like call a tow truck.

How a medical practice handles the problem is the first thing judged. Next, patients judge practices on the willingness to be sure the problem doesn’t reoccur. Look at Service Recovery as a mission involving three stakeholders:

1. Patients who want their complaint resolved
2. Employees who interact with the patient
3. Managers in charge of the process

Any “fix” should be an integrated one. Patients provide information, which managers and staff share throughout the practice. New structures and processes need to then be put into practice, and those new processes should make it easier to spot and fix problems.

If practice management is assuring the tools are there to deliver successful Service Recovery, then employees feel reassured, and achieve greater job satisfaction. Everyone in the medical practice is learning from the service failure, and making sure it doesn’t repeat itself. Remember that patients, like all customers, have more tolerance for poor service experienced once than for poor service recovery. If you repeat the failure, you’ll likely lose the patient because they feel you aren’t paying attention and the system won’t change.

Also, make it easy for patients to give feedback – positive and negative – it’s all important! Use:

• Surveys (keep them short and sweet)
• Interviews (impromptu during visits)
• Patient “hot lines”
• Critical incident surveys
• Suggestion leaflets (an anonymous drop-box)

Happily, studies have shown that if you recover well, you often find your patient (customer) is even more loyal than before!

DNA Snippet

“Customers don’t expect you to be perfect. They do expect you to fix things when they go wrong.” — Donald Porter, VP, British Airways

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Other consumer-dependent businesses, such as retail, hotels and airlines, drive loyalty through courtesy (or they could and should) but how does a medical practice do so? The same way, with a healthy dose of empathy and compassion to acknowledge people’s feelings. A medical practice that wants to invite patient loyalty must have staff that understands those values and puts them into daily practice.

Making courtesy and service excellence the drivers for your medical practice means you place those values in line with what patients indicate are the key drivers of their satisfaction and loyalty. As in the old corollary where when everything goes right, no one mentions it, in healthcare, no one notices a safe experience. Only when things do not seem safe, or “right” do patients notice. And patients do notice when processes are broken and staff are unhappy. It’s revealed through the service, or lack thereof.

Think about it: No organization ever became a great service organization with managers who place service and courtesy at the bottom of the priority list. There is no such thing as a sacred department or an untouchable staff member. If you want to attract and retain patients, you need to attract and retain the best and brightest staff for your medical practice.

Too, if the value of a happy customer (patient) is an invisible number – because how can you put a number on loyalty – then so is improved employee morale, as well as the subsequent productivity, that comes from cooperation and process improvement. There are two frequent barriers to service excellence:

1. Lack of communication between departments (the right hand doesn’t know what the left is doing)
2. Lack of cross-functional teamwork (the absence of one person halts an entire process because no one else understands how they contribute)

Both of these barriers lead to frustration and broken processes, and are often revealed not only in the bottom line, but also in employee attitude. If courtesy is in short supply within your medical practice, it’s a sign of a larger issue and should be explored more deeply.

Also, take notice of how all employees interact with each other, as well as with patients. Common courtesy shouldn’t be uncommon – “Please,” “Thank you,” “If you don’t mind” – all go a long way toward smoothing waters and soothing ruffled feelings. Management and physicians are not above the fray and should set the example to emphasize its importance.

Remember: People do not do what their organizations expect; they do what their managers pay attention to!

DNA Snippet
“Life is not so short but there is always time for courtesy.” — Ralph Waldo Emerson

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Things are changing in 2010 and our Oncology coding expert, Derry, Nolan & Associates’ medical practice consultant Gwen Davis, CPC, put together a few tips for our Oncology medical practice clients. It’s a good Evaluation and Management coding guidelines hotlist, so read on. Then, see today’s DNA Snippet for resources regarding Medicare Consults in 2010.

Manage Your Documentation (think EMR, Fee Tickets, MAR, Flowsheets & Coding)

• Keep updated tools and databases current
• Provide ongoing education to billing as well as clinical staff
• Hire certified coders and ensure regular interactions with physicians

Time-Based Billing Accuracy
Routinely, Oncologists have intense, sensitive “Life and Death” counseling sessions with patients and family members. For correct time-based billing, remember the following:

• More than 50% of the time you’re with a patient must be spent on counseling or coordination of care
• Face to face time counts, ancillary service provider time doesn’t – such as when a nurse is drawing blood. Also, should you leave Patient A to go check on Patient B and then return to Patient A, the time out-of-room does not count as Patient A time.
• Document clearly the time you spent and what was discussed, ensuring it is plausible and accounts for time claimed. No “cloning” from a previous patient or simple pasting of a generic statement about drugs and side effects, or using a blanket “spent 30 minutes counseling patient” statement.
  Suitable Documentation Example: Patient was here for 50 minutes; 30 minutes consisted of face-to-face counseling on end of life issues regarding his current diagnosis X, treatment options X, and side effects. Additional counseling discussing lifestyle changes (hospice, long term care) also took place.

Oncology Reimbursement Recommendations
Gwen mentions the importance of documentation as related to Oncology reimbursement and its associated regulations, “I routinely navigate complex regulations regarding expensive chemotherapy treatments. Right now, I’m developing tools that will help Oncology offices with the 2010 RAC and OIG regulations.” (Thanks, Gwen!) Her five quick recommendations are:

1. Know current FDA Indications (use the compendia!)
2. Document when you are going Off Label
3. Know current billing requirements
4. Watch those HCPCS Units
5. And finally, let your computer work for you. Flag your system to catch medically unlikely charges and work these audits prior to submitting claims. It will save time, money and headaches!

Understanding and Following Incident-to Requirements
This “last but not least” recommendation regarding documentation is about Incident-to criteria. Be sure to identify who rendered the service and that the direct supervision requirement was met. Show the physician’s initiation and continued involvement in the treatment, as well as showing that the services are reasonable and necessary. And be sure to show that the services are within the scope of practice for the non-physician practitioner.

Remember, correct documentation is the key to successful reimbursement!

DNA Snippet
Visit the Practice Resource Center at www.wsma.org for helpful guidelines to navigating Medicare Consults in 2010. Plus, the WSMA’s Coding Hotline gives great guidance on CPT, ICD-9 and HCPCS coding. Just call Michelle Lott, CPC at 1-800-552-0612.

As we’ve discussed, empathy is an integral part of customer (and patient) service. In fact, it’s critical for effective anger management. When we imagine ourselves in the other person’s situation, there’s an automatic shift in attitude, because we lower our own defenses. Companies who train employees to use empathy effectively win repeat customers.

Take Disney, for example. The company’s customer service attitude is explored in “If Disney Ran your Hospital: 91/2 Things You’d Do Differently,” by Fred Lee. Lee points to a process Disney employees use called L.A.S.T – Listen, Apologize, Solve the problem, Thank the person – as an example of effectively used empathy. Apologizing with empathy – “I wouldn’t like that either” or “If that happened to me, I would be upset too” – works. Rote, insincere apologies do not.

The same holds true in a medical practice. When you express empathy, you show acceptance of the patient’s feelings, you do not necessarily agree with how they express them. Empathetic phrasings like the below are examples:

“I hear what you’re saying”
“I know what you mean”
“I don’t blame you”
“I can understand that you…”

As part of the empathetic response, try re-framing, helping the patient change their point of view by sharing the benefits of the situation with them. For instance:

Patient: “Why do I have to drink this contrast; it’s tastes terrible!”
You: “I agree it doesn’t taste good. We have several flavors that might make it more palatable to you. Unfortunately, the contrast is necessary for accurate results.”

Selective agreement is another defusing skill. It allows you to agree in part with what the patient is saying and works well if they’re very angry and seem to be taking it out on you. It’s also a helpful tool when you feel yourself beginning to react negatively to the patient’s word or tone. Look for something you can agree with, even if it’s a very small part of what’s being said. Also, for selective agreement to work, remember to use a calm, quiet tone. Perhaps begin with:

“It does seem that way”
“I see your point”
“It’s tough to argue with that”

Empathy is appropriate for responding to frustration, fear or pain. The flip side is that you do not want to use empathy if the situation is out of control, with the patient attacking you, your team or your medical organization (more on this in a later post).

DNA Snippet
“When you choose to be pleasant and positive in the way you treat others, you have also chosen, in most cases, how you are going to be treated by others.” — Zig Ziglar

Medical practice staff juggle many responsibilities. Hectic days breed harassed and flustered employees, many of whom simply don’t have all the answers to patient questions. That’s when it’s easy for patience with the patients to slip.

The other side of the coin is policy. Many times, policy and procedures are set up without providing real life scenarios from which medical practice staff can draw. The simple solution is to be sure all employees have a good knowledge of not only policy and procedure, but also sample responses to tense or difficult situations.

There are all-too-common words to avoid that can kill patient loyalty and create unproductive interactions. But never fear, we’ve given you better words to use that can kindle patient loyalty. These power words and phrases let staff say, “Yes,” offer options, create confidence, get information, and be spontaneous and creative.

Notice the alternative phrasings of “helpful” invite cooperation, automatically placing staff in a positive, rather than adversarial, position.

unhelpful: “I don’t know.”
helpful: “I’m not sure I have the answer to that, but I can find out for you quickly.” or
“That’s a good question; let me get the answer for you.”

unhelpful: “That’s not my job.”
helpful: “Let me see what I can do to solve this.” or
“Let me get the expert for you!”

unhelpful: “We can’t do that” or “I don’t make the rules” or “It’s not our policy”
helpful: “I’m so sorry. I’m unable to because…” (give an explanation, not an excuse) or
“Well, you know what we could do.” or
“I wish I could do exactly that for you. Let’s see what we can work out instead.”

unhelpful: “It isn’t my fault.”
helpful: “That’s unfortunate. Let’s see how we can fix this.”

unhelpful: “The doctor is busy.”
helpful: “I’m so sorry. The doctor is with another patient right now, but I know this is something he’d want to know about. May I ask the nurse to help you in the meantime?”

unhelpful: “What’s your problem?”
helpful: “Why don’t you tell me about the difficulty you’re having.”

unhelpful: “I want you to…”
helpful: “Let me help you (do, get to) so we can figure this out.” or
“What would help us get this moving is if we could…”

Practice the sayings. Come up with ones that fit your particular medical practice and the situations your patients face. Practice some more. If you need help, give us a call! There’s a free one-hour consultation as part of every Derry, Nolan engagement.

DNA Snippet

“To my customer. I may not have the answer, but I’ll find it. I may not have the time, but I’ll make it.” — Unknown