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Tearful breakdowns and loud outbursts—they happen with orthopedic patients even in the best of practices. And if you are an orthopedic surgeon who has rarely or never experienced a patient in emotional distress, just talk with your staff—they have no doubt experienced this many times.
There is something about orthopedic conditions—they carry with them an increased likelihood of emotional adverse effects for patients and their loved ones. Inhibited movement can lead to palpable frustration and depression. Time off from work may cause financial hardship and an identity crisis for a family breadwinner. Physical pain can cause the patient to become depressed, angry, or dependent on prescription medication. Medications can cause a change in disposition or outlook. These realities make orthopedic surgery practices particularly predisposed to patient relations risks and service recovery opportunities.
As a practice management consultant and former executive director of an orthopedic practice, I have observed and participated in patient relations and service recovery efforts at many levels. Particularly proud of the way our staff and physicians prevented and handled these and having spent many years traveling by air under the color-coded TSA (Transportation Security Administration) security level indicator system, I created the Patient Relations and Service Recovery Guide (Figure) to help practices gain perspective, have a vocabulary, and develop practical methods for mitigating patient relations risks and responding to incidents and complaints.
The Patient Relations and Service Recovery Guide
The Patient Relations and Service Recovery Guide shows the relationship between the practice as a whole and the patient as an individual.
Green and Red
Green describes the elements of service orientation that the practice must consistently demonstrate and convey to each individual from the point of access, through treatment, and, finally, during account settlement. If you think you have a systemic problem with anything under the Green heading, you probably need a practice management or service orientation consultant, not this article. Red shows the other end of the spectrum—a complete degeneration, worst-case scenario. As with problems in the Green category, this article will not help you in these Red situations, for which you need experienced legal counsel immediately.
We’ll now explore the stories, challenges, opportunities, and practical suggestions for the Blue, Yellow, and Orange categories. The Blue and Yellow categories in the Figure are shaded in grey as a depiction of the interactive, fluid nature of these situations. In addition, they are situations that have developed and can be resolved within and by the practice.
Blue
Patients are very comfortable complaining to the receptionist, x-ray technician, and medical assistant about any number of perceived shortcomings, but when you walk in the examination room, not a word. This is a reality I am sure you have heard about from your staff, and it puts them in a position to observe and determine if a patient’s frustration is escalating. Telephone and front desk receptions are first in line. Patients will say to a telephone receptionist, “I have called 3 times yesterday and twice today and the doctor/nurse still hasn’t called back.” Front desk receptionists will also observe dynamics in the seating area. Staff are your partners in patient relations and service recovery. Working together effectively will help you address issues in the Blue and Yellow areas.
Create an environment that prevents patient discontent and supports service orientation goals. A hospital-based practice that I once managed was a flagship for service excellence goals of a Fortune 150 corporation, had a large seating area, and was close to the airport in a city with multiple company properties; we frequently had executives showing up unannounced, and, because of company politics, it seemed like they were actively looking for instances of substandard service. More importantly, though, we had patients. We established “Waiting Stories” as a performance standard for the receptionists. That is, at any moment, the receptionist was able to recap the “story” of each person in the seating area. The “story” is the reason the person was there, the appointment time, and the cause of the delay, if the wait time was excessive. We all knew this was a performance standard for our practice, so if a receptionist called back to the clinic to find out the reason for a backup in throughput, everyone was respectful and responsive to the inquiry.
The receptionists quickly became effective in judging situations and mitigating or avoiding breakdowns in service and communication. We also implemented an easy and quick notification code for when they needed help handling a service recovery situation. The responses and support in those situations were unwavering, consistent, and blame-free. We would debrief after a significant situation was resolved to determine if there were systemic or response improvement opportunities.
Communication among staff is essential for preventing or mitigating patient discontent. All practices experience service and throughput errors occasionally: a quiet, uncomplaining patient inadvertently doesn’t get called back and remains in the seating area unnoticed; a call doesn’t get returned; x-ray breaks down and a spine patient has to make a painful walk; the physician has to interrupt the encounter to take an important call; etc. Stuff happens. Individually, these breaches are tolerable to most patients. Unfortunately, there can be a cumulative element—when various service mishaps happen to the same patient. This is when communication and support among the staff and with the manager become especially important. If a patient has weathered a rough or long wait or has expressed some dissatisfaction while in the reception area, it’s probably a good idea to let the back-office staff know, so they can show a little extra compassion and be cognizant of additional situations.
Clinical staff and the physicians must convey support and appreciation to front-line staff who observe and share that a patient may be prone to distress, so that they will continue to participate in active incident prevention and service recovery.
Heightening awareness on the part of your staff—especially, receptionists, technicians, medical assistants, and collectors—goes a long way toward getting patient discontent issues settled before they get out of hand. As executive director of a large orthopedic surgery practice, I was particularly proud of our staff’s sensitivity to patient discontent, their sense of when it might be helpful to bring in a manager, and the managers’ ability both to recover many situations and to know when it was most effective to get help and support from either one of the executive team or physicians.
I can remember one patient that both front-line staff and the manager determined needed some service recovery intervention. She had been visibly upset at the end of her final postoperative visit with the physician. The staff noticed and called the manager in. The patient mentioned to the manager that she had been to another orthopedic surgeon who had told her that the surgery our physician had performed was not the right one and that he would have done things differently. The patient said she just didn’t know what to do. Our manager had the keen sense to know that she should get help to recover the situation within our practice. She and all of the staff were always supported when they asked for help, and the physicians were good about expressing their gratitude to the staff for their efforts. The manager escorted the upset patient to my office where we talked—well, she mostly talked and I listened. It turned out that her injuries had prevented her from attending games during her only child’s senior soccer season. I know, it sounds more like therapy—it was a lot of listening and compassion on my part. Eventually, she got around to thanking me for listening. And while that was not the end of it (there was another conversation), she did not take any action against our physician. See the “Talking It Through” Box.
Another group of staff who can identify issues is billing and collections. Often a patient will experience a minor cumulative series of service breaches (eg, long wait, perceived physician distraction, long hold times on the phone) and then lose it when they receive a bill that is incorrect, late, or confusing. The staff members answering those calls also need to feel supported in asking for help from a manager or another associate, either during the call or by suggesting that someone call the patient back.
Empowering staff or managers with tangible service recovery courtesies is also a good idea. We gave our staff coupons from the sundries shop in the building, so that when experiencing a particularly long wait, the patient could go down and get a complimentary snack. We also had 1 or 2 occasions when a patient drove a great distance to see the physician and experienced a significant service breach. As part of our response, we gave the patient a gas card.
Blue is the category in which the staff’s keen observation and true teamwork and support come into play when a situation or developing situation is identified.
Yellow
Yellow, while still contained within the practice, is overt. There has been an incident and/or a communication (letter or call) to the manager or physician. In Yellow, we are beyond the cooperative staff observation and sensory skills—we know something has happened. A situation might be physical- and/or facility-based, eg, a patient or family member had a minor stumble on a doormat, and though luckily they had not appeared injured and the physician checked them out, it was an incident. The other sign of a Yellow situation is that a patient or family member has written a letter to the practice to express their dissatisfaction. In either case, as dreadful as it may seem or as busy as you may be, follow up promptly.
In the case of an incident in the practice, the doctor or manager can call the patient that evening to check in and make sure all is well. Upon receiving a letter, the treating physician and manager should take a minute to discuss and agree on a response plan. Sometimes the situation may call for patient discharge from the practice—only the physician can determine that. Other times, the content of the letter may cause you to consult an attorney or your malpractice insurance carrier. The letters sometimes voice service-oriented complaints and can be addressed by the manager with a phone call and conversation as described in the Blue section above.
Orange
As a consultant, I have assisted many physicians in responding to individual patient complaints to their state medical board (SMB). I have seen a 15-page, single-spaced, typewritten letter with photographs (of the patient’s 70-lb pannus, no less), a 4-sentence letter in childlike grammar and handwriting, and many in between. The spelling, grammar, punctuation, coherence, and brevity of the letter do not matter. Your feelings on the validity of the complaint (ie, “That’s total BS!”) don’t matter. The perceived mental health of the patient (ie,“Well, he’s crazy! Ask my nurse.”) does not matter. Your SMB takes each and every complaint letter very seriously and so must you. One complaint spiraling out of control can be all it takes for you to lose your license. Having said that, individual patient SMB complaints are not uncommon; even the best physicians receive them.
Here are some thoughts to keep in mind regarding individual patient SMB complaints. An individual patient SMB complaint:
◾ Typically comes to you via US mail with no receipt signature required. Lots of us do so much online these days we can go weeks, perhaps months, without looking at our mail—even if staff members have opened it.
Suggestion: Make sure the staff looks at mail and is able to judge what requires action and what should be brought to your attention. Provide appreciation and detailed feedback when staff members bring something to you and do not misdirect negative reactions regardless of the content. You would rather staff members feel comfortable bringing something to your attention that is immaterial than keep something important from you out of fear of displeasing you.
◾ Includes a SMB response deadline that may give you as little as 1 or 2 weeks.
Suggestion: Meet the deadline. If you have or are going to miss the deadline or know that you cannot meet it, have your staff call the SMB office and abjectly request an extension.
◾ Is coming from physicians as members of the SMB, even though it may have the names of physicians you know, perhaps friends, on the letterhead.
Suggestions:
1. The physicians are not your colleagues in this situation. In this capacity, each physician is a member of an oversight board that serves and protects the people of your state. Don’t try to address the situation with a phone call or comment on the golf course.
2. Reply in the format the board has requested—a letter. Open your response letter with a statement that acknowledges the work and responsibility of the SMB and your appreciation, for example:
Esteemed Board,
While I regret that a patient complaint associated with me has come to your attention, I am grateful that the physicians and the people of [your state] have an oversight body to ensure the integrity of medical care delivered and received. Thank you for your service.
◾ Is likely to make you feel angry, indignant, unappreciated, hurt, bewildered, etc.
Suggestion: Breathe, vent to someone you can trust, exercise, get a good night’s sleep, and/or other calming, self-preservation tactics. Repeat as necessary so as not to allow these emotions a place in your response.
◾ May or may not include a request for a copy of the complete medical record.
Suggestion: If the medical record is not requested, do not send it. If the medical record is requested, send it in its entirety, as is. Do not make changes, edits, or amendments to the medical record as a response to the complaint.
◾ May be brief, vague, long, articulate, well thought-out and well structured, and/or ridiculous. Regardless of education level, profession, age, and socioeconomic status, any of your patients may write a complaint letter to the SMB, who then must address it.
Suggestions:
1. Demonstrate respect for the board’s time and service by writing a response letter of respectable length and substance regardless of the brevity of the complaint. Brief responses to the SMB may be perceived as arrogant and irreverent, and this is the exact situation and group of people in the entire state in which and before whom you do not want to be thought of that way.
2. Summarize the case with detail and substance in the letter, even if the medical record will be included in the response. Identify the actual complaints and address them in an organized way, an objective voice, and a logical order. Describe the time, thought, and follow-up you have put into addressing the situation. For instance, if the complaint includes a legitimate reference to a delay in test results or an unreturned phone call, provide a broad description of having reviewed and modified the process with your staff to understand where the gap occurred and having taken measures to help keep it from happening again.
◾ Will likely require that a copy of your response be made available or sent to the complainant.
Suggestions:
1. You are writing to 2, maybe 3, recipients: the SMB, the complainant, and the complainant’s attorney. Even if it is clear the patient did not consult a lawyer to write the complaint, it is best to write the response as though it will be read by an attorney.
2. Take the time and deliberation necessary for a multiple-draft writing process. Get help from someone to assure you have addressed all the issues in an organized, objective way.
◾ May lead to a request from the SMB that you appear before them in response to the original complaint letter and/or to clarify your response to a complaint letter. This is an indication of an investigation that has escalated beyond the patient SMB complaint letters addressed in this article; consult an experienced attorney who represents you.
Sometimes other state oversight bodies will receive complaints directly from patients and follow up with you. Consult your attorney, risk management consultant, or malpractice coverage representative for guidance if you are unsure as to the jurisdiction or how to respond.
Conclusion
Most of your practice operates in the Green, no doubt. It is simply not noticeable or memorable when everything goes smoothly. When incidents occur that require service recovery, I hope this guide and commentary will offer perspective on the full range of patient relations and service recovery, provide stories and experiences that might help, and offer general tips and suggestions.
Tearful breakdowns and loud outbursts—they happen with orthopedic patients even in the best of practices. And if you are an orthopedic surgeon who has rarely or never experienced a patient in emotional distress, just talk with your staff—they have no doubt experienced this many times.
There is something about orthopedic conditions—they carry with them an increased likelihood of emotional adverse effects for patients and their loved ones. Inhibited movement can lead to palpable frustration and depression. Time off from work may cause financial hardship and an identity crisis for a family breadwinner. Physical pain can cause the patient to become depressed, angry, or dependent on prescription medication. Medications can cause a change in disposition or outlook. These realities make orthopedic surgery practices particularly predisposed to patient relations risks and service recovery opportunities.
As a practice management consultant and former executive director of an orthopedic practice, I have observed and participated in patient relations and service recovery efforts at many levels. Particularly proud of the way our staff and physicians prevented and handled these and having spent many years traveling by air under the color-coded TSA (Transportation Security Administration) security level indicator system, I created the Patient Relations and Service Recovery Guide (Figure) to help practices gain perspective, have a vocabulary, and develop practical methods for mitigating patient relations risks and responding to incidents and complaints.
The Patient Relations and Service Recovery Guide
The Patient Relations and Service Recovery Guide shows the relationship between the practice as a whole and the patient as an individual.
Green and Red
Green describes the elements of service orientation that the practice must consistently demonstrate and convey to each individual from the point of access, through treatment, and, finally, during account settlement. If you think you have a systemic problem with anything under the Green heading, you probably need a practice management or service orientation consultant, not this article. Red shows the other end of the spectrum—a complete degeneration, worst-case scenario. As with problems in the Green category, this article will not help you in these Red situations, for which you need experienced legal counsel immediately.
We’ll now explore the stories, challenges, opportunities, and practical suggestions for the Blue, Yellow, and Orange categories. The Blue and Yellow categories in the Figure are shaded in grey as a depiction of the interactive, fluid nature of these situations. In addition, they are situations that have developed and can be resolved within and by the practice.
Blue
Patients are very comfortable complaining to the receptionist, x-ray technician, and medical assistant about any number of perceived shortcomings, but when you walk in the examination room, not a word. This is a reality I am sure you have heard about from your staff, and it puts them in a position to observe and determine if a patient’s frustration is escalating. Telephone and front desk receptions are first in line. Patients will say to a telephone receptionist, “I have called 3 times yesterday and twice today and the doctor/nurse still hasn’t called back.” Front desk receptionists will also observe dynamics in the seating area. Staff are your partners in patient relations and service recovery. Working together effectively will help you address issues in the Blue and Yellow areas.
Create an environment that prevents patient discontent and supports service orientation goals. A hospital-based practice that I once managed was a flagship for service excellence goals of a Fortune 150 corporation, had a large seating area, and was close to the airport in a city with multiple company properties; we frequently had executives showing up unannounced, and, because of company politics, it seemed like they were actively looking for instances of substandard service. More importantly, though, we had patients. We established “Waiting Stories” as a performance standard for the receptionists. That is, at any moment, the receptionist was able to recap the “story” of each person in the seating area. The “story” is the reason the person was there, the appointment time, and the cause of the delay, if the wait time was excessive. We all knew this was a performance standard for our practice, so if a receptionist called back to the clinic to find out the reason for a backup in throughput, everyone was respectful and responsive to the inquiry.
The receptionists quickly became effective in judging situations and mitigating or avoiding breakdowns in service and communication. We also implemented an easy and quick notification code for when they needed help handling a service recovery situation. The responses and support in those situations were unwavering, consistent, and blame-free. We would debrief after a significant situation was resolved to determine if there were systemic or response improvement opportunities.
Communication among staff is essential for preventing or mitigating patient discontent. All practices experience service and throughput errors occasionally: a quiet, uncomplaining patient inadvertently doesn’t get called back and remains in the seating area unnoticed; a call doesn’t get returned; x-ray breaks down and a spine patient has to make a painful walk; the physician has to interrupt the encounter to take an important call; etc. Stuff happens. Individually, these breaches are tolerable to most patients. Unfortunately, there can be a cumulative element—when various service mishaps happen to the same patient. This is when communication and support among the staff and with the manager become especially important. If a patient has weathered a rough or long wait or has expressed some dissatisfaction while in the reception area, it’s probably a good idea to let the back-office staff know, so they can show a little extra compassion and be cognizant of additional situations.
Clinical staff and the physicians must convey support and appreciation to front-line staff who observe and share that a patient may be prone to distress, so that they will continue to participate in active incident prevention and service recovery.
Heightening awareness on the part of your staff—especially, receptionists, technicians, medical assistants, and collectors—goes a long way toward getting patient discontent issues settled before they get out of hand. As executive director of a large orthopedic surgery practice, I was particularly proud of our staff’s sensitivity to patient discontent, their sense of when it might be helpful to bring in a manager, and the managers’ ability both to recover many situations and to know when it was most effective to get help and support from either one of the executive team or physicians.
I can remember one patient that both front-line staff and the manager determined needed some service recovery intervention. She had been visibly upset at the end of her final postoperative visit with the physician. The staff noticed and called the manager in. The patient mentioned to the manager that she had been to another orthopedic surgeon who had told her that the surgery our physician had performed was not the right one and that he would have done things differently. The patient said she just didn’t know what to do. Our manager had the keen sense to know that she should get help to recover the situation within our practice. She and all of the staff were always supported when they asked for help, and the physicians were good about expressing their gratitude to the staff for their efforts. The manager escorted the upset patient to my office where we talked—well, she mostly talked and I listened. It turned out that her injuries had prevented her from attending games during her only child’s senior soccer season. I know, it sounds more like therapy—it was a lot of listening and compassion on my part. Eventually, she got around to thanking me for listening. And while that was not the end of it (there was another conversation), she did not take any action against our physician. See the “Talking It Through” Box.
Another group of staff who can identify issues is billing and collections. Often a patient will experience a minor cumulative series of service breaches (eg, long wait, perceived physician distraction, long hold times on the phone) and then lose it when they receive a bill that is incorrect, late, or confusing. The staff members answering those calls also need to feel supported in asking for help from a manager or another associate, either during the call or by suggesting that someone call the patient back.
Empowering staff or managers with tangible service recovery courtesies is also a good idea. We gave our staff coupons from the sundries shop in the building, so that when experiencing a particularly long wait, the patient could go down and get a complimentary snack. We also had 1 or 2 occasions when a patient drove a great distance to see the physician and experienced a significant service breach. As part of our response, we gave the patient a gas card.
Blue is the category in which the staff’s keen observation and true teamwork and support come into play when a situation or developing situation is identified.
Yellow
Yellow, while still contained within the practice, is overt. There has been an incident and/or a communication (letter or call) to the manager or physician. In Yellow, we are beyond the cooperative staff observation and sensory skills—we know something has happened. A situation might be physical- and/or facility-based, eg, a patient or family member had a minor stumble on a doormat, and though luckily they had not appeared injured and the physician checked them out, it was an incident. The other sign of a Yellow situation is that a patient or family member has written a letter to the practice to express their dissatisfaction. In either case, as dreadful as it may seem or as busy as you may be, follow up promptly.
In the case of an incident in the practice, the doctor or manager can call the patient that evening to check in and make sure all is well. Upon receiving a letter, the treating physician and manager should take a minute to discuss and agree on a response plan. Sometimes the situation may call for patient discharge from the practice—only the physician can determine that. Other times, the content of the letter may cause you to consult an attorney or your malpractice insurance carrier. The letters sometimes voice service-oriented complaints and can be addressed by the manager with a phone call and conversation as described in the Blue section above.
Orange
As a consultant, I have assisted many physicians in responding to individual patient complaints to their state medical board (SMB). I have seen a 15-page, single-spaced, typewritten letter with photographs (of the patient’s 70-lb pannus, no less), a 4-sentence letter in childlike grammar and handwriting, and many in between. The spelling, grammar, punctuation, coherence, and brevity of the letter do not matter. Your feelings on the validity of the complaint (ie, “That’s total BS!”) don’t matter. The perceived mental health of the patient (ie,“Well, he’s crazy! Ask my nurse.”) does not matter. Your SMB takes each and every complaint letter very seriously and so must you. One complaint spiraling out of control can be all it takes for you to lose your license. Having said that, individual patient SMB complaints are not uncommon; even the best physicians receive them.
Here are some thoughts to keep in mind regarding individual patient SMB complaints. An individual patient SMB complaint:
◾ Typically comes to you via US mail with no receipt signature required. Lots of us do so much online these days we can go weeks, perhaps months, without looking at our mail—even if staff members have opened it.
Suggestion: Make sure the staff looks at mail and is able to judge what requires action and what should be brought to your attention. Provide appreciation and detailed feedback when staff members bring something to you and do not misdirect negative reactions regardless of the content. You would rather staff members feel comfortable bringing something to your attention that is immaterial than keep something important from you out of fear of displeasing you.
◾ Includes a SMB response deadline that may give you as little as 1 or 2 weeks.
Suggestion: Meet the deadline. If you have or are going to miss the deadline or know that you cannot meet it, have your staff call the SMB office and abjectly request an extension.
◾ Is coming from physicians as members of the SMB, even though it may have the names of physicians you know, perhaps friends, on the letterhead.
Suggestions:
1. The physicians are not your colleagues in this situation. In this capacity, each physician is a member of an oversight board that serves and protects the people of your state. Don’t try to address the situation with a phone call or comment on the golf course.
2. Reply in the format the board has requested—a letter. Open your response letter with a statement that acknowledges the work and responsibility of the SMB and your appreciation, for example:
Esteemed Board,
While I regret that a patient complaint associated with me has come to your attention, I am grateful that the physicians and the people of [your state] have an oversight body to ensure the integrity of medical care delivered and received. Thank you for your service.
◾ Is likely to make you feel angry, indignant, unappreciated, hurt, bewildered, etc.
Suggestion: Breathe, vent to someone you can trust, exercise, get a good night’s sleep, and/or other calming, self-preservation tactics. Repeat as necessary so as not to allow these emotions a place in your response.
◾ May or may not include a request for a copy of the complete medical record.
Suggestion: If the medical record is not requested, do not send it. If the medical record is requested, send it in its entirety, as is. Do not make changes, edits, or amendments to the medical record as a response to the complaint.
◾ May be brief, vague, long, articulate, well thought-out and well structured, and/or ridiculous. Regardless of education level, profession, age, and socioeconomic status, any of your patients may write a complaint letter to the SMB, who then must address it.
Suggestions:
1. Demonstrate respect for the board’s time and service by writing a response letter of respectable length and substance regardless of the brevity of the complaint. Brief responses to the SMB may be perceived as arrogant and irreverent, and this is the exact situation and group of people in the entire state in which and before whom you do not want to be thought of that way.
2. Summarize the case with detail and substance in the letter, even if the medical record will be included in the response. Identify the actual complaints and address them in an organized way, an objective voice, and a logical order. Describe the time, thought, and follow-up you have put into addressing the situation. For instance, if the complaint includes a legitimate reference to a delay in test results or an unreturned phone call, provide a broad description of having reviewed and modified the process with your staff to understand where the gap occurred and having taken measures to help keep it from happening again.
◾ Will likely require that a copy of your response be made available or sent to the complainant.
Suggestions:
1. You are writing to 2, maybe 3, recipients: the SMB, the complainant, and the complainant’s attorney. Even if it is clear the patient did not consult a lawyer to write the complaint, it is best to write the response as though it will be read by an attorney.
2. Take the time and deliberation necessary for a multiple-draft writing process. Get help from someone to assure you have addressed all the issues in an organized, objective way.
◾ May lead to a request from the SMB that you appear before them in response to the original complaint letter and/or to clarify your response to a complaint letter. This is an indication of an investigation that has escalated beyond the patient SMB complaint letters addressed in this article; consult an experienced attorney who represents you.
Sometimes other state oversight bodies will receive complaints directly from patients and follow up with you. Consult your attorney, risk management consultant, or malpractice coverage representative for guidance if you are unsure as to the jurisdiction or how to respond.
Conclusion
Most of your practice operates in the Green, no doubt. It is simply not noticeable or memorable when everything goes smoothly. When incidents occur that require service recovery, I hope this guide and commentary will offer perspective on the full range of patient relations and service recovery, provide stories and experiences that might help, and offer general tips and suggestions.
Tearful breakdowns and loud outbursts—they happen with orthopedic patients even in the best of practices. And if you are an orthopedic surgeon who has rarely or never experienced a patient in emotional distress, just talk with your staff—they have no doubt experienced this many times.
There is something about orthopedic conditions—they carry with them an increased likelihood of emotional adverse effects for patients and their loved ones. Inhibited movement can lead to palpable frustration and depression. Time off from work may cause financial hardship and an identity crisis for a family breadwinner. Physical pain can cause the patient to become depressed, angry, or dependent on prescription medication. Medications can cause a change in disposition or outlook. These realities make orthopedic surgery practices particularly predisposed to patient relations risks and service recovery opportunities.
As a practice management consultant and former executive director of an orthopedic practice, I have observed and participated in patient relations and service recovery efforts at many levels. Particularly proud of the way our staff and physicians prevented and handled these and having spent many years traveling by air under the color-coded TSA (Transportation Security Administration) security level indicator system, I created the Patient Relations and Service Recovery Guide (Figure) to help practices gain perspective, have a vocabulary, and develop practical methods for mitigating patient relations risks and responding to incidents and complaints.
The Patient Relations and Service Recovery Guide
The Patient Relations and Service Recovery Guide shows the relationship between the practice as a whole and the patient as an individual.
Green and Red
Green describes the elements of service orientation that the practice must consistently demonstrate and convey to each individual from the point of access, through treatment, and, finally, during account settlement. If you think you have a systemic problem with anything under the Green heading, you probably need a practice management or service orientation consultant, not this article. Red shows the other end of the spectrum—a complete degeneration, worst-case scenario. As with problems in the Green category, this article will not help you in these Red situations, for which you need experienced legal counsel immediately.
We’ll now explore the stories, challenges, opportunities, and practical suggestions for the Blue, Yellow, and Orange categories. The Blue and Yellow categories in the Figure are shaded in grey as a depiction of the interactive, fluid nature of these situations. In addition, they are situations that have developed and can be resolved within and by the practice.
Blue
Patients are very comfortable complaining to the receptionist, x-ray technician, and medical assistant about any number of perceived shortcomings, but when you walk in the examination room, not a word. This is a reality I am sure you have heard about from your staff, and it puts them in a position to observe and determine if a patient’s frustration is escalating. Telephone and front desk receptions are first in line. Patients will say to a telephone receptionist, “I have called 3 times yesterday and twice today and the doctor/nurse still hasn’t called back.” Front desk receptionists will also observe dynamics in the seating area. Staff are your partners in patient relations and service recovery. Working together effectively will help you address issues in the Blue and Yellow areas.
Create an environment that prevents patient discontent and supports service orientation goals. A hospital-based practice that I once managed was a flagship for service excellence goals of a Fortune 150 corporation, had a large seating area, and was close to the airport in a city with multiple company properties; we frequently had executives showing up unannounced, and, because of company politics, it seemed like they were actively looking for instances of substandard service. More importantly, though, we had patients. We established “Waiting Stories” as a performance standard for the receptionists. That is, at any moment, the receptionist was able to recap the “story” of each person in the seating area. The “story” is the reason the person was there, the appointment time, and the cause of the delay, if the wait time was excessive. We all knew this was a performance standard for our practice, so if a receptionist called back to the clinic to find out the reason for a backup in throughput, everyone was respectful and responsive to the inquiry.
The receptionists quickly became effective in judging situations and mitigating or avoiding breakdowns in service and communication. We also implemented an easy and quick notification code for when they needed help handling a service recovery situation. The responses and support in those situations were unwavering, consistent, and blame-free. We would debrief after a significant situation was resolved to determine if there were systemic or response improvement opportunities.
Communication among staff is essential for preventing or mitigating patient discontent. All practices experience service and throughput errors occasionally: a quiet, uncomplaining patient inadvertently doesn’t get called back and remains in the seating area unnoticed; a call doesn’t get returned; x-ray breaks down and a spine patient has to make a painful walk; the physician has to interrupt the encounter to take an important call; etc. Stuff happens. Individually, these breaches are tolerable to most patients. Unfortunately, there can be a cumulative element—when various service mishaps happen to the same patient. This is when communication and support among the staff and with the manager become especially important. If a patient has weathered a rough or long wait or has expressed some dissatisfaction while in the reception area, it’s probably a good idea to let the back-office staff know, so they can show a little extra compassion and be cognizant of additional situations.
Clinical staff and the physicians must convey support and appreciation to front-line staff who observe and share that a patient may be prone to distress, so that they will continue to participate in active incident prevention and service recovery.
Heightening awareness on the part of your staff—especially, receptionists, technicians, medical assistants, and collectors—goes a long way toward getting patient discontent issues settled before they get out of hand. As executive director of a large orthopedic surgery practice, I was particularly proud of our staff’s sensitivity to patient discontent, their sense of when it might be helpful to bring in a manager, and the managers’ ability both to recover many situations and to know when it was most effective to get help and support from either one of the executive team or physicians.
I can remember one patient that both front-line staff and the manager determined needed some service recovery intervention. She had been visibly upset at the end of her final postoperative visit with the physician. The staff noticed and called the manager in. The patient mentioned to the manager that she had been to another orthopedic surgeon who had told her that the surgery our physician had performed was not the right one and that he would have done things differently. The patient said she just didn’t know what to do. Our manager had the keen sense to know that she should get help to recover the situation within our practice. She and all of the staff were always supported when they asked for help, and the physicians were good about expressing their gratitude to the staff for their efforts. The manager escorted the upset patient to my office where we talked—well, she mostly talked and I listened. It turned out that her injuries had prevented her from attending games during her only child’s senior soccer season. I know, it sounds more like therapy—it was a lot of listening and compassion on my part. Eventually, she got around to thanking me for listening. And while that was not the end of it (there was another conversation), she did not take any action against our physician. See the “Talking It Through” Box.
Another group of staff who can identify issues is billing and collections. Often a patient will experience a minor cumulative series of service breaches (eg, long wait, perceived physician distraction, long hold times on the phone) and then lose it when they receive a bill that is incorrect, late, or confusing. The staff members answering those calls also need to feel supported in asking for help from a manager or another associate, either during the call or by suggesting that someone call the patient back.
Empowering staff or managers with tangible service recovery courtesies is also a good idea. We gave our staff coupons from the sundries shop in the building, so that when experiencing a particularly long wait, the patient could go down and get a complimentary snack. We also had 1 or 2 occasions when a patient drove a great distance to see the physician and experienced a significant service breach. As part of our response, we gave the patient a gas card.
Blue is the category in which the staff’s keen observation and true teamwork and support come into play when a situation or developing situation is identified.
Yellow
Yellow, while still contained within the practice, is overt. There has been an incident and/or a communication (letter or call) to the manager or physician. In Yellow, we are beyond the cooperative staff observation and sensory skills—we know something has happened. A situation might be physical- and/or facility-based, eg, a patient or family member had a minor stumble on a doormat, and though luckily they had not appeared injured and the physician checked them out, it was an incident. The other sign of a Yellow situation is that a patient or family member has written a letter to the practice to express their dissatisfaction. In either case, as dreadful as it may seem or as busy as you may be, follow up promptly.
In the case of an incident in the practice, the doctor or manager can call the patient that evening to check in and make sure all is well. Upon receiving a letter, the treating physician and manager should take a minute to discuss and agree on a response plan. Sometimes the situation may call for patient discharge from the practice—only the physician can determine that. Other times, the content of the letter may cause you to consult an attorney or your malpractice insurance carrier. The letters sometimes voice service-oriented complaints and can be addressed by the manager with a phone call and conversation as described in the Blue section above.
Orange
As a consultant, I have assisted many physicians in responding to individual patient complaints to their state medical board (SMB). I have seen a 15-page, single-spaced, typewritten letter with photographs (of the patient’s 70-lb pannus, no less), a 4-sentence letter in childlike grammar and handwriting, and many in between. The spelling, grammar, punctuation, coherence, and brevity of the letter do not matter. Your feelings on the validity of the complaint (ie, “That’s total BS!”) don’t matter. The perceived mental health of the patient (ie,“Well, he’s crazy! Ask my nurse.”) does not matter. Your SMB takes each and every complaint letter very seriously and so must you. One complaint spiraling out of control can be all it takes for you to lose your license. Having said that, individual patient SMB complaints are not uncommon; even the best physicians receive them.
Here are some thoughts to keep in mind regarding individual patient SMB complaints. An individual patient SMB complaint:
◾ Typically comes to you via US mail with no receipt signature required. Lots of us do so much online these days we can go weeks, perhaps months, without looking at our mail—even if staff members have opened it.
Suggestion: Make sure the staff looks at mail and is able to judge what requires action and what should be brought to your attention. Provide appreciation and detailed feedback when staff members bring something to you and do not misdirect negative reactions regardless of the content. You would rather staff members feel comfortable bringing something to your attention that is immaterial than keep something important from you out of fear of displeasing you.
◾ Includes a SMB response deadline that may give you as little as 1 or 2 weeks.
Suggestion: Meet the deadline. If you have or are going to miss the deadline or know that you cannot meet it, have your staff call the SMB office and abjectly request an extension.
◾ Is coming from physicians as members of the SMB, even though it may have the names of physicians you know, perhaps friends, on the letterhead.
Suggestions:
1. The physicians are not your colleagues in this situation. In this capacity, each physician is a member of an oversight board that serves and protects the people of your state. Don’t try to address the situation with a phone call or comment on the golf course.
2. Reply in the format the board has requested—a letter. Open your response letter with a statement that acknowledges the work and responsibility of the SMB and your appreciation, for example:
Esteemed Board,
While I regret that a patient complaint associated with me has come to your attention, I am grateful that the physicians and the people of [your state] have an oversight body to ensure the integrity of medical care delivered and received. Thank you for your service.
◾ Is likely to make you feel angry, indignant, unappreciated, hurt, bewildered, etc.
Suggestion: Breathe, vent to someone you can trust, exercise, get a good night’s sleep, and/or other calming, self-preservation tactics. Repeat as necessary so as not to allow these emotions a place in your response.
◾ May or may not include a request for a copy of the complete medical record.
Suggestion: If the medical record is not requested, do not send it. If the medical record is requested, send it in its entirety, as is. Do not make changes, edits, or amendments to the medical record as a response to the complaint.
◾ May be brief, vague, long, articulate, well thought-out and well structured, and/or ridiculous. Regardless of education level, profession, age, and socioeconomic status, any of your patients may write a complaint letter to the SMB, who then must address it.
Suggestions:
1. Demonstrate respect for the board’s time and service by writing a response letter of respectable length and substance regardless of the brevity of the complaint. Brief responses to the SMB may be perceived as arrogant and irreverent, and this is the exact situation and group of people in the entire state in which and before whom you do not want to be thought of that way.
2. Summarize the case with detail and substance in the letter, even if the medical record will be included in the response. Identify the actual complaints and address them in an organized way, an objective voice, and a logical order. Describe the time, thought, and follow-up you have put into addressing the situation. For instance, if the complaint includes a legitimate reference to a delay in test results or an unreturned phone call, provide a broad description of having reviewed and modified the process with your staff to understand where the gap occurred and having taken measures to help keep it from happening again.
◾ Will likely require that a copy of your response be made available or sent to the complainant.
Suggestions:
1. You are writing to 2, maybe 3, recipients: the SMB, the complainant, and the complainant’s attorney. Even if it is clear the patient did not consult a lawyer to write the complaint, it is best to write the response as though it will be read by an attorney.
2. Take the time and deliberation necessary for a multiple-draft writing process. Get help from someone to assure you have addressed all the issues in an organized, objective way.
◾ May lead to a request from the SMB that you appear before them in response to the original complaint letter and/or to clarify your response to a complaint letter. This is an indication of an investigation that has escalated beyond the patient SMB complaint letters addressed in this article; consult an experienced attorney who represents you.
Sometimes other state oversight bodies will receive complaints directly from patients and follow up with you. Consult your attorney, risk management consultant, or malpractice coverage representative for guidance if you are unsure as to the jurisdiction or how to respond.
Conclusion
Most of your practice operates in the Green, no doubt. It is simply not noticeable or memorable when everything goes smoothly. When incidents occur that require service recovery, I hope this guide and commentary will offer perspective on the full range of patient relations and service recovery, provide stories and experiences that might help, and offer general tips and suggestions.