'Mystery shoppers' can uncover ED weaknesses

'Patients' present unannounced, report findings

The next patient you see in your ED may be a "mystery shopper" — and you won't even know it. Companies, such as Devon Hill Associates in San Diego, are being retained by hospital CEOs to have individuals come to their facilities to be "treated" and to report back on their findings. The findings then are shared with the different departments in the hospital, with an eye toward improving patient safety and satisfaction.

While the individual patient/mystery shopper will not be known, the ED manager probably will not be totally blindsided. "If I'm doing it, I insist they tell the entire hospital that mystery shopping will take place as part of their quality improvement or patient satisfaction plans," says Barbara Gerber, MPH, CHE, a former hospital administrator who is founder and president of 10-year-old Devon Hill. "Usually, all department managers will know." However, she adds, the ED manager would not now the "when" or the "who" of the visit.

Gerber says a project solely involved the ED would cost between $7,000 and $10,000 and involve three to five mystery shoppers. "It's better with five," she asserts. There are a few other companies that provide similar services, she adds, including Dee Peterson & Associates in Houston, and Perception Strategies in Indianapolis.

Bruce G. Jones, DO, medical director of the ED at Doctors Hospital in Columbus, OH, says, "As an ED director, I think this is a good thing. Anything that can provide valuable information to improve your process or the physical plant or interactions with patients is a valuable thing in your management role."

Jones says there have been mystery shoppers in his department. As a physician, Jones reacts a bit differently to what he calls the "dishonesty" of the scenario. "As an ED doc, I may have seen one and not known it, and clinically thought it was really a patient," he shares.

Gerber concedes that is a valid concern. "It always comes up in the ED. People ask why they should take care of three people who are not real patients when it takes time away from treating some very sick patients," she says. "While that's valid, the CEO will respond that out of thousands of visits a year, 70% to 80% may not be real emergencies; and if the ED can't take care of three patients out of the 15,000-20,000 nonemergent patients they might see, then they really have a problem."

How it works

Gerber, who says she has posed as an ED patient many times, says her company creates a variety of scenarios. She would not, however, provide much detail.

"A lot depends on the area we are in, but in general we use scenarios where the illness or condition is such that no one will be able to pick the fact that we are not real patients," she says.

Some pseudoconditions are minor, while others are more major, she continues. "We are able to do this because we have a number of mystery shoppers who have conditions that might make it necessary to go through certain processes or procedures," Gerber explains.

There are certain issues that show up often in EDs, says Gerber. "We frequently find a lack of good communication — not letting people know how long they might expect to wait," she notes. "People are left alone in rooms with no communication for 40 or 50 minutes."

Gerber says she often has been handed a form and not been told what it was that she was supposed to be signing. "A lot of that happens with a busy ED, and staff forgets they really need to communicate," she asserts.

Discharge instructions are another area where EDs commonly fall short, she continues. "Instead of having them explained in a manner the patient understands, the provider is gone very quickly, and the patient leaves not knowing what they are supposed to do," she asserts.

Gerber has also observed a lot of little things that she would correct. For example, patients often are not offered a pillow, asked which gurney position they prefer, or asked whether they want the TV turned on. "These things would make them feel they mean something to the caregiver," she notes.

EDs take note

Several EDs visited by Gerber or her staff have made important improvements following the visit. "Some EDs have developed systems where someone on the staff makes rounds on patients every 15-20 minutes — or they might have a patient advocate or volunteer responsible for making those visits," she shares.

Her mystery shoppers frequently uncover safety issues, such staff not wearing gloves or not washing or sanitizing their hands in front of the patients. "Maybe they do it between patients, but the perception is that it is not happening," she explains. "When it has been brought to their attention, some EDs have had sanitizers installed in the rooms so the process is now more obvious."

While Jones says he has not yet received any feedback from mystery shopper visits, he prefers to take a broader, more process-oriented approach. "We track productivity per doc every hour of every day, as well as a lot of other measures," he says.


For more information on mystery shoppers in the ED, contact:

  • Barbara Gerber, President, Devon Hill Associates, San Diego, CA. Phone: (858) 456-7800. E-mail: Barbara@devonhillassociates.com.
  • Bruce G. Jones, DO, Medical Director, Emergency Department, Doctors Hospital, Columbus, OH. Phone: (614) 544-1810.