Urgent message: Patients are the ultimate judges of the quality of care you provide, and the opinions are likely to be swayed by factors that have little to do with your clinical expertise or skill.
Alan A. Ayers, MBA, MAcc

Service industries – from retail stores to restaurants, hotels, and even banks – have embraced the customer’s point of view by meshing contemporary design, cutting-edge technology, and process engineering to develop services that are increasingly affordable and convenient.

But what about healthcare? Healthcare expenditures topped 17% of U.S. gross domestic product in 2008, according to the National Coalition for Health Care, and healthcare is one of the nation’s largest service industries. But despite its prominence in the economy, healthcare is plagued with rising costs, decreased accessibility, and increased hassle for patients.

Fortunately, an urgent care center isn’t any ordinary doctor’s office – it’s a delivery model that provides care on patients’ terms. Locations in high-traffic retail or residential areas, the ability to walk in without an appointment, extended evening/weekend hours, services for the entire family, and affordable pricing make urgent care more comparable to other service industries than to conventional medical providers. Because of this, patients are likely to compare the service at an urgent care center with that they have experienced at retail stores, restaurants, and other retail establishments that have invested significantly in the customer experience.

Thus, the opportunity for urgent care operators is to redefine quality along retail standards by answering the most pressing questions: Is the patient please? Pleasing patients depends on delivering an experience consistent with patient expectations; how well urgent care centers embrace quality from the patient’s perspective will determine their future growth and profitability.

Redefining Quality in Urgent Care

There are many ways to define quality in healthcare. Historically, standards have focused on the structure of the medical establishment (e.g., adequacy of facilities and equipment, qualification of providers, and degree of administrative oversight), clinical processes and decision making, and medical outcomes. While all of these criteria are relevant to professional practice, the recipients of care – patients – are usually unqualified to attach meaning to such measures.

By contrast, leading service companies have long understood that if consumers don’t like the experience provided, they won’t return and they’ll tell others to do the same. That’s why it’s patients – not academics, accreditation agencies, or statistics – who ultimately define “quality. And whether an urgent care center delivers “quality” depends on how closely the actual delivery of the service (i.e., the patient experience) compares with what the patient expected.

Clearly, to attain satisfaction, a patient must believe that medical reason for the visit was met – but sour employees, bumpy processes, and dowdy facilities can still undermine the best medical outcomes, resulting in patient perceptions of a very poor quality experience. (Table 1 illustrates how medical practice is only one of five dimensions of service quality.)

If an urgent care center wants to convey quality, it must understand patient expectations of quality and mange service delivery to ensure an experience consistent with those expectations.

Table 1. Categories of Patient Expectations1

Patient expectations of service quality are categorized across five dimersions:1
Reliability: Ability to perform promised services dependably and accurately.
Tangibles: Appearance of physical facilities, equipment, personnel, and communication materials.
Responsiveness: Willingness to help customers and provide prompt service.
Assurance: Knowledge and courtesy of employees and their ability to convey trust and confidence.
Empathy: Caring, individualized attention provided to the customer.
It’s important to note that only one attribute – reliability – concerns the service outcome. The remainder of the patient’s quality evaluation focuses on the process of service delivery and factors such as the physical environment and the friendliness, competence, and caring attitude of the provider and staff.

Understanding Patient Expectations

Given the relationship between patient expectations and experiences in defining quality, urgent care operators should consider first and foremost the implications of any business decision on patient perceptions – including people (i.e., hiring and training of providers and staff), processes (i.e., registration, billing, and collections), and physical evidence (i.e., layout and design of the physical facility and other tangibles).

Before a patient ever crosses the threshold of an urgent care center, she has some basic expectations as to what the experience will entail. Patient expectations may be:
Explicit: What the urgent care center, through its advertising and service model, promises to deliver.
Implicit: Not directly stated, but inferred by patients from attributes such as price, location, or appearance of the facility.

Based on word of mouth: What friends, family members, and virtual communities say about their experiences frame expectations for future patients. Based on past experience: Past experiences not only determine whether patients will return or recommend to others, but they also shape future encounters.

Once in the center, patient expectations continue to be shaped – and experiences delivered – through the interaction of people, processes, and physical evidence. For each, the urgent care operator must understand – and deliver an experience consistent with – patient expectations.

People Putting the Patient First

Successful urgent care centers seek to hire people with a positive attitude who understand the importance of not just doing their job tasks, but anything else that will contribute to a positive patient experience. Provider and staff attitudes towards the experience.

Mobilizing people to deliver a quality experience starts with understanding that patients want to be treated as individuals versus impersonally being “processed” through a system. A quality experience, therefore, entails greeting patients as they walk through the door, calling them “Mr.” or “Mrs.,” assisting them in filling out forms, respecting their privacy, asking if they understand for doctor’s orders, and thanking them for their patronage.

Understanding patient expectations can help providers and staff anticipate patient needs before they’re expressed while demonstrating the required skill to solve patient problems and showing genuine concern for the patient’s well-being.

Process: Mapping the Patient Experience

While many urgent care centers conduct patient surveys that evaluate services after the fact, planning good patient experiences also involves directly observing patient behavior in the clinic environment and organizing focus groups to capture patient ideas.

As illustrated by Figure 1, developing a service map is similar to developing a process flow diagram in that both evaluate all activities taking place – the difference being that a service map does so only form the patient’s point of view. Using observed or simulated patient experiences, the service map illustrates exactly what a patient see, hears, feels, touches, tastes, and even smells in the center.

Direct observation validates a service map by demonstrating instances where patients act outside of the process – for example, interrupting registration to request a change of the television channel. When developing a service map, particular attention should be paid to patient interactions with providers, staff, and the physical environment.

In addition to improving operational processes, the data in service maps can be used to increase effectiveness of providers and staff (e.g., in writing job descriptions or developing training) and to identify enhancements to the physical facility.

Figure 1. Service Map The service map evaluates all aspects of the patient experience—from the patients’ perspective—including what the patients do, where they move, and what they see, think, hear, and say.

Physical Evidence: The Servicescape

Service delivery is intricately coupled with the physical environment – which in marketing is referred to as the “servicescape.”2 Urgent care operators should make perfecting the servicescape a priority because it:

  • influences the patient’s initial reaction to the urgent care center and affects the patient’s ongoing mood during the visit; what are the patient’s initial cues to quality coming through the door, and is the overall environment welcoming or intimidating, calming or stressful?
  • differentiates from competitors; could a patient distinguish your urgent care facility from a competitor if all signage were removed?
  • facilitates a transaction; is signage visible and worded in such a way that patients readily understand, and is the facility layout intuitive such that patients move in a logical, orderly fashion and that staff can treat patients with minimal number of steps and obstacles?
  • creates a social environment; does the space facilitate or hinder communication between and among patients. staff, and providers?

Physical evidence encompasses the servicescape and all other tangible aspects of the experience, as detailed in Table 2. The goal of creating a service environment conductive to good patient experiences, and that also differentiates an urgent care center from competitors, is why many urgent care operators invest in retail-facing locations with comfortable furnishings and a polished fit and finish.

Table 2. Tangible Evidence of Urgent Care Quality

The patient’s perception of the quality of urgent care services is heavily influenced by the physical environment in which they’re delivered (also called the “servicescape”), as well as by other tangible aspects of the experience.
Facilities Exterior

  • Signage type, size, design, and visibility
  • Building design and architecture
  • Landscape and lighting
  • Traffic accessibility and parking
  • Surrounding environment
  • Overall curb appeal
Other Tangibles

  • Employee dress or uniforms
  • Point of sale marketing materials
  • Brochures, magnets, and other collateral
  • Patient forms, billing statements, and receipts
  • Magazines, refreshments, and other “comforts”
Facilities Interior
  • Interior design and décor
  • Equipment and furnishings
  • Directional and informational signage
  • Layout and ease of movement
  • Air quality and temperature
  • Lighting, music/video, and scent
  • Overall ambiance

 

Exceeding Patient Expectations

A frequent cliché when speaking about the patient experience is the goal of “exceeding patient expectations.”
The problem with this is that it sets the bar higher for future experiences. The goal shouldn’t be to exceed patient expectations, but to meet them consistently.

For example, the first time I worked on assignment in San Francisco, the hotel upgraded my stay to a corner room with floor-to-ceiling windows providing a magnificent view of the city and bay. The room far exceeded my expectations for the corporate rate pate. On my next trip I booked the same hotel, only to be disappointed when I ended up on the fifth floor overlooking a rooftop air conditioning unit.

The hotel delivered the product it promised – the downtown location, comfortable bed, and exercise facilities – but my expectations on the total experience had been artificially raised so much on my first visit that I was disappointed when I returned.

Similar experiences occur when a new urgent care center – without an established patient base – is able to offer quick service and personalized attention. But once volume ramps up, wait times may begin to extend and the staff soon scrambles to quickly process patients. Repeat patients are likely to comment “service has really gone downhill” when in reality, the experience simply normalized after expectations had been set.

Measuring Service Quality

Because service is the difference between patient expectations and experience, the only effective way to evaluate service quality is to ask patients to describe their visits to the center. Such can be accomplished by quantitative and qualitative methods.

Transactional survey assess patient experiences immediately after their visits and utilize touch-screen kiosks, comment cards, and mail, e-mail, or telephone questionnaires. When asked to score various elements on a scale of 1 to 10, impressions can be quantified and tracked – both across centers and over time – while also providing performance-based data for employee incentives and management rewards.

While quantitative data may be directionally accurate, one shortcoming is that they don’t distinguish among differing patient expectations. In addition, aggregated data cannot be used to remedy specific instances of poor service. Written patient comments provide more detail as to patient expectations and experiences.

Qualitative feedback is particularly useful in responding to specific patient issues. But in order for qualitative feedback to effort organizational change, a classification scheme must be developed to identify the most frequent types of patient feedback and trends over time. In most cases, patient comments are used to provide anecdotal evidence for data contained in qualitative measures.

The disadvantage of all patient surveys is that they don’t measure the experience of non-patients, such as referral sources or patients who balked before being served. In addition, dissatisfied patients often don’t respond to surveys but rather, “vote with their feet.”

Return on Service Quality Investment

Providing a quality patient experience does require investment – in people, processes, physical assets, and measurement systems. The link between these investments and profits is not direct, although intuition and experience indicate that it does exist.

Consider the lifetime value of a patient who returns twice a year, every year, for the next 30 years. Not only is such a patient a reliable source of revenue, but it satisfied, will pay a price premium for future services while recommending the center to others.

By contrast, when a dissatisfied patient leaves, marketing costs must be incurred to attract a new patient and to counterbalance any negative word of mouth. Investments made to improve the patient experience contribute to top-line revenue through increased volume and prices while also reducing overhead through improved operations efficiency.

Conclusion
Urgent care is distinct from other healthcare providers – and similar to retail and other service industries – in its orientation around patient affordability, convenience, and ease of use. Therefore, patients measure the service provided against retail-oriented business that have invested significantly in the patient experience.
Building a quality urgent care operation involves observation and data analysis to understand patient expectations and then developing people, processes, and physical environments that will deliver an experience consistent with those expectations.

References

  1. Parasuraman A. Berry LL, Zeithaml VA. Understanding customer expectations of service. Sloan Management Review. 1991; Spring: 39-48.
  2. Booms BH, Bigner MJ. Marketing strategies and organizational structures for service firms. In: Donnelly JH, George WR, eds. Marketing of Services. Chicago, IL: American Marketing Association; 1981: 47-51.
Putting Patients First: Redefining Quality in the Patient Experience

Alan A. Ayers, MBA, MAcc

President of Experity Consulting and is Practice Management Editor of The Journal of Urgent Care Medicine
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