Today's consumers experience high levels of service from Internet booksellers who seem to know them personally, credit card companies who process information instantaneously and banks with ATM machines that seem to always be just where they need them. So it's no surprise that when their physicians and other health care providers ask the same questions repeatedly, can't find lab results and rarely seem to be available when needed, it affects their willingness to return.

The quality of care you provide may do little to make up for shortcomings in the quality of service your patients receive.

Unfortunately, the quality of care you provide may do little to make up for shortcomings in the quality of service patients receive when they visit your practice. Research suggests patients have a hard time separating the two. A study by the Picker/Commonwealth Program for Patient-Centered Care suggests that patients define "care" in terms of service. Among the measures patients identified were respect for a patient's values, preferences and expressed needs; access to care; information, communication and education; and continuity.¹

This article will provide you with the information and tools you need to assess and improve your practice's current level of service.

Identifying your "moments of truth"

To better understand the level of service your practice provides, you can perform a simple "moment-of-truth" analysis with the help of your practice partners and staff. In health care, a moment of truth is a moment when the patient experiences some interaction and forms a judgment about the quality of the practice. Of course, good service is always important, but at moments of truth it's crucial.

KEY POINTS: A "moment of truth" occurs when a patient interacts with a practice and forms a judgment about its quality. A simple moment-of-truth analysis will help you understand the level of service your practice provides. You can improve your practice's service through rapid cycles of small "tests of change."

For example, a moment of truth occurs when the physician walks into the exam room. The physician's behaviors and body language in the first few seconds set the stage in the patient's mind for a good or bad interaction. The patient may notice whether the doctor makes immediate eye contact or enters looking down at the medical record, and whether the doctor gives the impression that he or she is relaxed and ready to listen or harried and just wanting to move things along.

The purpose of analyzing moments of truth is twofold: to create a service mind-set in your practice and to identify some priorities for improvement. The sample moment-of-truth worksheet can guide your analysis. The first column lists potential moments of truth (e.g., when patients call for an appointment), and the second column suggests ways to assess them using observation or measurement (e.g., the number of rings before the phone is answered). In addition to the suggestions listed on the worksheet, you may want to develop some of your own ideas. One way to do this is to post one moment of truth per day on bulletin boards in central locations and encourage others (including patients!) to jot down assessment ideas as they think of them. Be sure that the assessment items you come up with are stated in observable or measurable terms as seen through the patient's eyes. For example, "friendly staff" is too vague. Say instead, "patients get the impression that the staff enjoys working with patients." And although "time spent searching for medical record" is measurable, it is not seen through the patient's eyes. Rather, "time spent in the waiting room before being called back to exam room" captures the patient's experience of service in the office.

What level of service are you providing?

Once your worksheet is complete, there are a number of simple ways you can measure and assess your practice's level of service for each moment of truth you've identified:

• Observation. Look around your office. Is the telephone first answered by a person or a machine?
• Automated data collection. Some telephone systems can automatically keep track of average time on hold.
• Pencil-and-paper strategies. For example, you might have a nurse write the rooming time on a note and stick it on the exam-room door, and then have the doctor write his or her time of entry on the same note and drop it in a box for later summary analysis.
• Patient feedback. Give patients a colored marble as they exit and ask them to respond to the item of the day (e.g., "the doctor really listened to me today") by dropping the marble in one of five glass cylinders corresponding to their response - strongly agree, agree, neutral, disagree or strongly disagree. The result is a bar chart of service satisfaction at the end of the day!
• Personal experience. Call in on the normal appointment line to see for yourself how quickly the phone is answered and how pleasant the greeting sounds.

SAMPLE MOMENT-OF-TRUTH WORKSHEET [See other tool in this article.] Moment of truth Potential assessment items Calling for an appointment Number of rings before an answer Answered by person or machine Number of menu levels to navigate; number of choices at each level Number of calls immediately put on hold Time on hold Pleasantness/sincerity of first human contact Variance between desired appointment and given appointment Getting to the office Ease with which new patient can find the practice Parking lot "cruise time" Number of steps from parking lot to office Reception Time to first greeting Pleasantness/sincerity of first human contact Clarity of instruction for check-in process, and the frequency with which patients get it wrong or need to ask for help Time required to complete check-in paperwork (for new and existing patients) Number of redundant requests for information (for new and existing patients) Waiting room Time in waiting room Nurse call-back Number of times staff pronounces patients' names incorrectly Pleasantness/sincerity of greeting Whether staff makes eye contact Comfort and privacy of taking vitals What the nurse asks the patient (e.g., reason for visit, what the patient hopes will happen at the visit), and the variance of questioning from other staff Sitting in the exam room Length of wait (average and variability) Whether staff provides an estimate of the wait and the accuracy of the estimate How often the patient is updated on waiting time The activities provided for patients while they wait Comfort of the exam room First impression of the clinician Whether the clinician greets the patient while looking directly at him or her Clinical interaction Time to first interruption by clinician, and frequency of interruptions Whether the patient feels that the clinician listened to him or her Whether the patient was able to say all that he or she wanted to say Satisfaction with the overall interaction Clinical closure Whether relevant written materials are available for the patient Check-out Time to first greeting Pleasantness/sincerity of human contact Clarity of instruction and process flow, and the frequency with which patients get it wrong or need to ask for help Time required to complete paperwork (for new and existing patients) Number of redundant requests for information Whether future appointments are offered or confirmed Copyright © 2002 Tim Porter-O'Grady and Paul E. Plsek. Physicians may photocopy for use in their practices; all other rights reserved. "Building a Mind-Set of Service Excellence." Plsek P. Family Practice Management. April 2002:41-46, www.aafp.org/fpm/20020400/41buil.html.

However you choose to assess your practice's moments of truth, keep it simple, involve staff in coming up with creative approaches and have some fun. See your practice through the patient's eyes. Don't get hung up on statistical questions or worry about getting large samples. You are not writing a research paper; rather, you are becoming more aware of trends in the service you provide to your patients.

Each round of focus and improvement builds momentum toward a mind-set of service excellence.

Setting priorities for change

After measuring and assessing your practice's level of service, you may find that your practice's performance is far from ideal. If you want a different level of service in your practice, you will have to change something. But rather than trying to fix all the problems at once, you will need to set some priorities.

It is important to involve your practice partners and staff in this priority-setting process just as it was in the moment-of-truth analysis. If you can arrange a large staff meeting, do that; but there is no need to give in to the tyranny of another meeting. The information from the assessment could be distributed in a brief report that asks everyone to rank or vote on topics for improvement via a bulletin board or form. Or you could appoint a small group that represents a slice of professional and office staff to go through the items and select eight or 10 that could then be put before the entire staff; then use the input to narrow the choices to two or three for initial action. You might even consider involving a few patients you know will be constructive in providing input.

As you set priorities, ask yourself the following questions:

• In what areas is our performance far from ideal?
• What improvements do we think our patients will notice most?
• Where do we think we can be successful in making change?
• What groups of clinicians and staff should we involve in each item, and what is their readiness to change?

Don't spend a lot of time agonizing over what to put first on your list. Just pick something that matters and where there seems to be a critical mass of partners and staff willing to do something about it, and get started.

Keep in mind that after you choose an area and make improvements to it (see the section "Conducting tests of change," below), you will choose another area and repeat the process. Service improvement is a never-ending task. Each round of focus and improvement builds momentum toward a mind-set of service excellence.

Conducting tests of change

Once you've completed a moment-of-truth analysis and identified your priorities for change, you can begin to actually make changes in your practice's level of service. The illustration below presents a common-sense approach to improvement made up of rapid cycles of small "tests of change."

As you can see in the model, improvement begins with focus - picking something to work on. Next, the current level of performance needs to be measured in a simple way that doesn't require the rigorous measurement of a research study (the moment-of-truth assessment typically provides an adequate baseline measurement). The essence of improvement is change, so the next logical step is to intervene and try something different. Then measure the level of performance again. If more improvement is needed, intervene and change something else. The point is to use common sense, try various things and measure frequently. Keep these tests of change going until you are more satisfied with your level of performance than you were when you began and you feel ready to focus on another area. [For an example of a test of change that might be done in a family practice, See "A test of change."]

A TEST OF CHANGE This material is not included in the print version of the article. Following is an example of how a group of doctors might construct a small "test of change" to find out how they can improve their listening skills with patients to ultimately improve the practice's level of service. Suppose a practice has asked patients for several days in a row to respond with agreement or disagreement to the statement, "The doctor really listened to me today." Further suppose that 75 percent of patients responded with neutrality or disagreement. One of the practice partners suggests that the physicians maintain eye contact and wait for the patient to pause before saying anything. Some of the doctors are eager to try it, but others think it is a crazy idea that will result in lengthening the visit time. Rather than allowing the disagreement to result in inaction, the eager partners decide to try it. All the doctors agree that the check-out staff should continue asking the listening question but should separate the responses for the participating doctors from the others. The doctors also agree to compare visit time and productivity measurements, which have historically been gathered and are fairly similar among them. After three days, the doctors who have varied their practice have reduced their poor listening scores from about 75 percent to 30 percent, while the other doctors have remained in the 75-percent range. The visit time and productivity measurements show no significant increase in visit time, and the variability is no more or less than it has been in the past. Are the doctors satisfied with this overall level of improvement? Probably not. But what to do next will depend on the circumstances. If some of the doctors are not convinced that the three-day test proves anything, the participating doctors might continue the test for several more days with another look at the measurements later. After the additional days, some of the initially skeptical doctors might agree to participate, involving more patients in the next test. Or, some of the doctors might decide to go even further by telling patients that they are working on listening better and inviting them to tell the doctors if they feel they are not being listened to. In the end, though the change process is quick and perhaps "unscientific," if more of the participating doctors' patients say that they feel listened to, then this group of doctors has improved their practice's level of service in a small but significant way.

The following four discussion questions (incorporated in the "model-for-improvement" worksheet) will help guide you and others in your practice as you conduct your own tests of change:

1. Aim setting: What are we focusing on now, and what is our goal? Describe the area of improvement you want to focus on (your chosen priority), and determine the point of satisfaction for that area. State the aim in patient-oriented terms, and set a measurable goal. You shouldn't set perfection as your standard, but your goal should be ambitious enough that you have to think of fundamentally different ways of doing things and that you wouldn't be embarrassed to tell your patients about it. For example, wouldn't you prefer your patients see that you set a 90-percent goal for answering the phone within five rings rather than a 50-percent goal?

If a small test of change improves some aspect of patient service, you're better off than you were before.

2. Measurement: How will we know if we are making it better? The key is to choose practical measurement over perfect measurement. Keep it simple. Think of measurement as a feedback loop, and make the feedback rapid. For example, if you are working on listening to patients more, get their feedback immediately as they leave rather then waiting weeks or months for data from a more formal, mailed questionnaire. Often, it is not so much the absolute level of what you are measuring that counts but simply whether it is trending up or down. Also, consider additional "balancing measures" - other things that could get worse while you are making changes. For example, if you are working to reduce patients' time in the waiting room, you should also measure overall visit time and/or time in the exam room; reducing time in the waiting room doesn't do any good if the patient just waits somewhere else.

3. Idea generation: What changes do we think will make it better? Ideas for improvement can come from a variety of sources. You may have read about something or heard about it from a colleague or at a conference. The idea may come from some other setting (e.g., you may be impressed with the way some other business handles scheduling and decide to bring some of its approaches into your practice). The idea could also come from logical thinking (e.g., it makes sense that patients will feel better served if the nurses write the phonetic spelling of the patient's name on the chart and the doctor fully scans the history, closes the chart before opening the exam-room door, enters making eye contact and greets the patient, correctly pronouncing his or her name). Idea generation might also involve creative thinking that challenges the way things have always been done (e.g., providing flu shots in a drive-up service in the parking lot).

A MODEL FOR IMPROVEMENT This worksheet walks you through the process of testing changes for improvement in your practice. Discuss and jot down ideas for each of the four questions and use the tips to guide you through each discussion. (Download a PDF file of this worksheet.) Discussion questions Discussion tips Aim setting: What are we focusing on now, and what is our goal? Set aims from the point of view of your patients (i.e., what would they want you to work on?). Set your aims high ("stretch goal") - even halfway there would be a substantial improvement. Look to make substantial progress in a matter of weeks. Measurement: How will we know if we are making it better? Provide feedback on performance and change using data. Collect data pre- and post-change. Avoid long baseline studies that postpone getting to the change. Keep it simple. Choose practical measurement over perfect measurement. Keep the time between intervention (action) and measurement to a minimum. Idea generation: What changes do we think will make it better? Think about the rules and mental constructs that underlie the current way of doing things. This is the "box" that our current thinking is in. Get outside the box by asking: "Does it have to be that way?" "What would it be like if we were prohibited from following that rule?" "If we broke those rules, would that be so bad after all?" Turn needed behavioral changes into specific techniques that people can learn. For example, instead of "listen to the patients' concerns," try "ask the patient if there is anything else, make eye contact and silently count to 10 before you say anything more." Always generate multiple ideas for change. There may be legitimate reasons why a certain idea cannot be tested. If that is your only idea, then momentum is stopped. Testing: How will we carry out progressive trials of our ideas? People are more likely to go along with a test of change if they are involved in the planning of it. Don't get attached to any one way of implementing an idea. Stay at the change-concept level, and allow others the joy of developing the specifics to fit their situation. Start small and work initially with those willing to work with you. Use the success of these few to approach others. Improvement is always a "work in progress"; it is not a one-time event. Work to keep the momentum going. Take the biggest step you can take, but don't worry that you are not doing it all. One step can lead to another, and so on. Be sure to allocate time to reflect on the results of every test of change and its implications for the next test. Integrate improvement into regular work. For example, allocate office meeting time for this. Always be testing a change and letting everyone know about it. Anticipate the impact of the change on other players in the system. Keep them informed - no surprises. Don't let the unwilling stop you from testing a change with those who are willing, but don't do anything behind anyone's back. Communicate, communicate, communicate ... repeat. Don't lose sight of the whole system as you work on a small piece of it. Don't let analysis interfere with synthesis. Copyright © 2002 Tim Porter-O'Grady and Paul E. Plsek. Physicians may photocopy for use in their practices; all other rights reserved. "Building a Mind-Set of Service Excellence." Plsek P. Family Practice Management. April 2002:41-46, www.aafp.org/fpm/20020400/41buil.html.

4. Testing: How will we carry out progressive trials of our ideas? The only way to know if an idea will work for you is to try it and see what happens. Think small-scale and rapid-cycle: What can I do in the next few days that will give me more insight into whether this idea will work for our practice? Quickly plan a test; carry it out; reflect on the results and your experience doing it; and then decide if you want to keep going with the idea, modify it and try again, or discard it in favor of another idea. Expect to conduct several such cycles, maybe with several different ideas, in order to reach the goal stated in your aim. Remember that others are more likely to go along with change if they are involved in planning it. Don't get attached to any particular way of doing tests of change; allow others the joy of working out the specifics. Work initially with the willing, but keep everyone informed of what you are doing so that no one is surprised.

The criticism of this approach to improvement is that it is "unscientific" and that, in the end, you won't know which of several changes made the biggest difference and won't be able to generalize the findings without randomization and more rigorously collected data. This may be a valid criticism, but so what? If a small test of change improves some aspect of patient service, you're better off than you were before. We rarely demand to see the evidence supporting the status quo, but we often subject change ideas to a higher standard. We are not talking about clinical interventions here - where certainly a higher standard of evidence should be adhered to - we are talking about improving the patients' experience of care and service in the practice.

A service mind-set

Providing good service is not just a frill in family practice. It can influence outcomes, help improve staff morale and lead to greater engagement of patients in shared decision making. Good service matters. The simple, common-sense approaches presented here, when thoughtfully adapted to the style and pace of a family practice, can help you begin to engage your professional partners and staff in building a service mind-set.

1. Gerteis M, Edgman-Levitan S, Daley J, Delbanco TL, eds. Through the Patient's Eyes: Understanding and Promoting Patient-Centered Care. San Francisco: Jossey-Bass;1993.

Paul Plsek is an Atlanta-based consultant in quality improvement, leadership and innovation who specializes in health care. He is also a senior fellow at the Institute for Healthcare Improvement in Boston. Conflicts of interest: none reported. The author would like to acknowledge Tim Porter-O'Grady, PhD, EdD, FAAN, for his substantial contributions to the ideas in this article.

Send comments to fpmedit@aafp.org.

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