Medical Mystery Shopping in the News

When James Loden, an ophthalmologist, recently peered into a patient's eyes, he was evaluating her for laser surgery to correct her vision. But her eyes were sharp enough to have already scanned Dr. Loden's Nashville, Tenn., office, noting a small water stain on the ceiling in the hallway, the technician's missing name tag, and that exactly 55 minutes elapsed between when she came in the door and when she was seen.

This patient, armed with a quick smile and a hidden tape recorder, was actually a "mystery shopper" from a service paid by Dr. Loden to evaluate his own office. After her appointment, she sat in her car and jotted down notes for her employer, Las Vegas-based Examine Your Practice, which then reported back to Dr. Loden on the experience.

"Perception is reality," says Dr. Loden, who has made a number of changes in his practice based on reports from mystery shoppers. "The patient's perception is all that really matters."

The health-care industry has never been noted for its customer service. But as competition builds amid efforts to encourage patients to comparison-shop for health care, medical facilities and hospitals are increasingly looking for ways to improve the patient experience. Some are turning to mystery-shopping services -- a mainstay of the retail and hotel industries -- which send employees to pose as customers and later report back on how they were treated.

Although health-care mystery shopping made up just 2% of the $600 million in revenue for the mystery-shopping industry in 2004 -- the latest data available from the Mystery Shopping Providers Association -- medical revenues doubled from the prior year. "Before 18 months ago, we hadn't had a single inquiry from health care," says Jeff Hall, president of Ann Arbor, Mich.-based Second to None Inc., a general mystery-shopping company. "We fielded half a dozen in the last year."

Health-care facilities that use mystery shoppers say the reports have led to a number of changes in the patient experience, including improved estimates of wait times, better explanations of medical procedures, extended hours for hospital administration workers, escorts for patients who have gotten lost, and even less-stressful programming on the television in the waiting room.

One big impetus for focusing on patient experience: Beginning Oct. 1, the U.S. Centers for Medicare and Medicaid Services will begin assessing patient satisfaction at hospitals across the country and making that data public. Patients can already compare some measures of clinical care at a Department of Health and Human Services Web site, www.hospitalcompare.hhs.gov . But the new survey will be the first time potential patients can directly compare satisfaction scores across hospitals nationwide.

"No one wants to be at the bottom of the list," says Brad Neet, president of Saint Michael's Hospital in Stevens Point, Wis., who enlisted mystery-shopping patients in his hospital in December 2004. The experience spurred the hospital to improve how it communicates what patients can expect during an exam, and the purpose of tests, says Mr. Neet.

Patient satisfaction is also being incorporated more frequently into hospital executive pay. More than 55% of hospital chief executive officers surveyed last year have "some compensation at risk," based on patient satisfaction, up from only 8% to 10% a dozen years ago, according to Mel Hall, president and CEO of Press Ganey Associates Inc., a South Bend, Ind., company specializing in patient-satisfaction assessment that commissioned the study.

Mystery-shopping services work in a number of ways. Generally, the hospital or doctor's office will know only a range of time during which mystery patients may show up, which can run anywhere from a week to a year. In some cases patients reveal themselves at the end of a visit. Other times the facility may never know who the mystery patients were. Generally, patients pose as uninsured patients, and the fees for health care are paid by the health-care facility.

Mystery patients may make inquiries over the phone, go to a doctor's office or emergency room for a checkup, or in extreme cases, fake symptoms. Barbara Gerber, president of medical mystery-shopping company Devon Hill Associates in La Jolla, Calif., says she once kept hospital staff fooled for 12 hours that she had multiple sclerosis so she could check out a rehabilitation hospital's inpatient unit.

To remember details while remaining undercover, shoppers resort to hiding tape recorders in their bags, jotting details down in appointment books or crosswords, and going to bathrooms to take notes.

Observations can range from the minor to the serious. Courtney Lee once posed as an uninsured patient for 24 hours on an inpatient unit at a Midwestern hospital for Indianapolis-based Perception Strategies mystery-shopping service. When she asked for an additional pillow, she says a nurse said to her, "Why don't you have your husband or friend get you one from the dollar store?"

The hospital was also noisy, according to Ms. Lee, who got a headache from being awakened by staffers walking into her room. "By the time I left, I was exhausted," says Ms. Lee, who was pretending to have the flu.

Medical mystery shopping can raise some thorny issues -- among them the fear that mystery patients will take up time and resources needed by truly sick patients. Mystery-shopping firms say that when shoppers are evaluating emergency rooms, they may be told to visit only during less-busy hours, so they won't make suffering patients wait to see medical staff.

Hospitals and doctor's offices typically tell their staff that mystery shoppers will be showing up (without saying exactly when) and staff and doctors sometimes feel spied on. The medical facilities say that staffers usually do come around and learn to appreciate the value of improving service. And mystery patients also note positive interactions.

OhioHealth, a nonprofit organization of 15 hospitals and other health-care services in Ohio, began rewarding employees who got praise from mystery shoppers with small cash prizes, gift cards, better parking spaces, and public recognition, such as engraving their name on a wall plaque. (The program now includes feedback from other patients and staff, too.) OhioHealth's employee turnover rate dropped to 11.5% in 2006 from nearly 18% in 2000, in part due to the new incentives, says Becky Zuccarelli, system vice president for customer service. OhioHealth spent $44,000 on mystery shopping with Perception Strategies, which covered 240 mystery patient visits over one year. The organization has since established in-house mystery shopping.

When Medical City Dallas Hospital learned from reports by Devon Hill shoppers that patients' level of psychological comfort was low, the hospital developed new scripts for speaking with customers. Now, rather than just asking "Can I get anything for you?" staffers are told to add, "I have the time," according to Britt Berrett, Medical City's CEO and president.

Medical City also simplified terminology and enlarged the font on its signs in response to mystery-shopper complaints. Mr. Berrett says the more than $10,000 the hospital spent on the shopper service was "the best money I ever spent."

Dr. Loden, the Nashville ophthalmologist, responded to his shopper feedback by spending more time with his patients during the initial, free consultation for laser eye surgery and is addressing patient wait times. The percentage of patients who decided after consultation to go through with the surgery rose to over 70% in June and July from 50% in May, which was before he made any changes based on the shopper reports. While it isn't definitive that mystery shopping is the reason for this increase, Dr. Loden says that he is pleased and plans to continue hiring mystery patients on a yearly basis as a checkup.

For years, the retail and hospitality industries have put themselves under the microscope of a group of patrons whose job it is to inspect and evaluate their every move. They’re called mystery shoppers and their goal is to help companies improve customer service. In the growing environment of patient-centered health care, hospitals and physician practices are taking the cue from customer service industries and enlisting the watchful eye of mystery patients.

Mystery patients are employed by companies like Devon Hill Associates, a La Jolla, California-based firm that works with large health care facilities across the country. Founder Barbara Gerber, a former hospital administrator who had created a business mystery shopping occupational health and assisted-living settings, conceived the idea of pursuing hospital clients during what she called a “dismal” hospital stay.

“I put on my consumer hat and decided I wanted to make the hospital experience better,” Gerber explained. “I put the program together knowing that hospitals would never be the whole part of my business.”

That was in 1996, and today, 10 years later, Gerber splits her mystery shopping between long-term care and hospital clients, who are becoming increasingly interested in customer service—an area in which, Gerber asserted, there’s a great need.

“People in hospitals get caught up in the important, lifesaving things they have to do, and they sometimes forget about the service part,” she said. “Up until recently, there was really no need, but now that consumers are going to pay more and be able to compare pricing at different facilities, there will be an increase in demand for better customer service.”

Devon Hill Associates sends its mystery patients on a variety of assignments for its hospital clients, from the emergency department to outpatient surgery centers. Mystery patients pursue the experience all the way up until the actual surgery in order to evaluate service every step of the way.

“Most of the things they’re looking for have to do with communication: Is the provider telling them who they are and what their role is,” Gerber explained. “Patients are asking ‘Do you care about me and are you sensitive to my situation?’ I had someone go through the ER and comment that the triage nurse rolled through the list of questions without waiting for responses. That certainly has an impact on how a person feels the hospital cares about them.”

Gerber relayed that there has been some negative response from health care professionals who feel that people posing as patients take away from actual patients who need care.

“But then the hospital CEOs say that if they, as a hospital, can’t take care of three extra patients, then they really have a problem,” she added. “But they still don’t like someone looking over their shoulder.”

Still, Gerber’s mystery patients are trained to evaluate both bad and good in the hospital setting. “There are a lot of good things we find and report,” she said. “Then the nurses and other staff get extra recognition that they wouldn’t otherwise receive.”

While Devon Hill Associates focuses on large facilities, a Las Vegas-based company called Examine Your Practice sends its mystery patients to the private offices of fee-for-service providers, such as plastic surgeons, ophthalmologists and dentists. Jodi Manfredi, the company’s founder and president, created Examine Your Practice after years in dental sales.

“Being in the dental industry for so long, I saw the need for mom-and-pop practices to evaluate their customer service,” Manfredi said. “I had doctors telling me that patients were leaving their practice but they didn’t know why. That’s when the light bulb went on.”

Manfredi first saw her business model attracting specialized, non-insurance-based practices, which remain the bulk of her business, but she pointed out that she has been receiving inquiries from hospital-owned private practices that are insurance driven.

“Doctors want to start measuring patient satisfaction,” she explained. “They know that patients have more options and they want to go where they want to go, and they want to go somewhere that makes them feel good emotionally—not just physically—when they leave.”

Manfredi explained that the qualified mystery patients she hires go into physician’s offices for noninvasive procedures or consultations and evaluate everything from the first phone call to set up an appointment to the actual visit itself. Each physician client receives nine mystery visits each year, with six patients “shopping” within the first three months. An entire physician shop extends over the course of a year, after which the client is presented with a thorough review of all six shoppers’ evaluations. “Checkup shots” evaluate the practice’s progress based on the shoppers’ and the company’s recommended action steps.

“Plus, the shoppers and evaluations aren’t trained to just find what’s wrong,” Manfredi added. “They’re also trained to know what’s right. I’ve even had people accept plans from dentists or go in for whatever procedure they were shopping during the consultation. Thanks to the mystery patients, some doctors gain actual patients.”

Two careers in dental offices helped Jodi Manfredi of Henderson create a national business that's based on common sense.

Dentists — really, all kinds of doctors — get clients by word-of-mouth recommendations, and those are earned by things like friendly smiles, a nice waiting room and personable physicians.

"How do you cut your marketing cost? It's a lot less if it's referrals and it's free," says Manfredi, who has been a dental assistant and a dental supplies saleswoman.

Manfredi incorporated Examine Your Practice a year ago, but business recently picked up last fall after the Vision Expo in Las Vegas for eye doctors. Her concept is a twist on mystery shopper companies, which traditionally evaluate customer service at retail stores and restaurants.

An interesting facet is that the company is based in Henderson, even though Nevada has the most restrictions in the union for mystery shoppers. Shoppers have to be employees of a company, rather than freelancers, and that company has to be overseen by a licensed private investigator.

That's why clients in Nevada pay $3,500, while elsewhere they pay $3,000 for the service.

At Examine Your Practice, an unexpected turn came when recruiting started. Manfredi put an ad in the Arizona Republic, and was soon flooded with requests — from potential mystery shoppers. After the first ad, on a Wednesday, the business had 50 applicants. The second ad on Sunday raised it to almost 200.

Money tips Web sites such as volition.com and mom-mom.com caught on quickly, and Manfredi network has grown to more than 900 shoppers.

"We're the buzz," she said. Shoppers are drawn to the higher pay, about twice that of doing a retail shop, and the perks, which can include a free exam.

And now Manfredi can afford to be picky: She will only hire experienced shoppers with certification through the Mystery Shopping Providers Association.

The company hires shoppers to begin with a series of six visits. Shoppers from different demographics go in for a variety of non-invasive visits, such as a dental cleaning or a consultation for plastic surgery.

Shoppers fill out a thorough online evaluation within 24 hours, and the client receives it in 48 hours. After the blitz, as she calls it, there are some followups.

Manfredi recommends that doctors wait until after the first six to tell the staff about the service. Rewarding them for good service is better than criticizing the weaknesses.

The service was recently performed at the Henderson dental practice of two brothers, Drs. James and John Nassar.

"I thought they would be, they were very favorable reports," John Nassar said. "They were very thorough, it's not like they said, 'Everything is great.' "

Nassar said the office had already starting cutting down on external marketing.

In comparison, a typical newspaper campaign for a medical office would be $16,000 for one month. A local radio station may cost $2,000 to $3,000 per month, according to Robertson Wood Advertising in Las Vegas.

"It's important to do some marketing to have your name out there and the exposure," Nassar said. "But we really believe in internal marketing and in-house referrals. Really how we've built our practice the last few years, people are happy with the service and treatment and send others."

Examine your practice is offering a new take on the secret shopper concept. The company hires people to get services and evaluate dentists, plastic surgeons, veterinarians and other fee for services medical practices. [Jodi Manfredi], who has worked in the dental industry for many years, launched Examine your practice in Phoenix and is now offering the service nationally.

Manfredi wouldn’t say how much patients get paid, through they do receive compensation in addition to free services. SAY WHAT? The company Examine your practice uses mystery patients to evaluate the services delivered by dental offices.

Copyright Boston Herald Library Mar 29, 2006

Why would you go to the dentist if you didn’t have to?

Examine Your Practice is offering a new take on the secret shopper concept. The company hires people to get services and evaluate dentists, plastic surgeons, veterinarians and other fee- for-services medical practices.

“We want to know how patients felt when they left and whether they would refer other patients,” said Examine's founder, Jodi Manfredi.

Nearly everyone has heared a dentist horror story. Long waits, rude staff, dirty bathrooms, pain.

All of that adds up to lost business. In an increasingly competitive business, customer service matters as much as good dentistry.

Manfredi, who has worked in the dental industry for many years, launched Examine your practice in Phoenix and is now offering the service nationally. Manfredi wouldn't say how much patients get paid, through they do receive compensation in addition to free services.

Though doctors may be concerned about secretly checking on their staff, it can be turned into a positive thing, Manfredi said, Reports can be used to offer bonuses and help improve conditions for employees, as well as patients.

Mystery patients evaluate such things as how long they're put on hold when they call whether they're treated with respect, how long the wait is to see the doctor and whether the bathrooms are clean, as well as the overall experience, including possibly the level of pain inflicted.

The company has already signed up 860 mystery patients throughout the country. They get free services and a fee for their work.

John E. Nasser, a Nevada dentist, said he hired the company because he strives to maintain a high level of service.

“We keep an ear out for how the staff talks to the patients, but it was nice to have someone come in and critique the office,“ he said.

He is still waiting for the final analysis, but the preliminary reports are good. Two mystery patients have even decided to stay with the practice.

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