QI doesn’t end when the doctors say they’re happy

Strive for a high rating, but don’t stop there

If there’s one thing a Michigan agency’s quality manager has learned, it’s that a customer satisfaction survey can always be improved.

For more than a year, Huron Valley Visiting Nurses of Ann Arbor, MI, has been sending surveys to 150 physicians who make patient referrals. The six-month surveys have consistently shown that the physicians are happy with the agency’s services.

About 20% of the surveys are returned, and there are few low scores on them.

But that worries Susan Johnson, acting director of quality management and director of advancement and special programs. The private, nonprofit agency serves southeast Michigan and parts of Ohio.

Johnson says the target response rate is 30%, but the lower rate is understandable because physicians tend to be too busy to answer surveys.

The real problem is that the agency has received little negative feedback from the returned surveys. The target referral source satisfaction level is 90%, and the agency has consistently achieved 99% for overall satisfaction with employees.

"The reason we’re not happy with it is our scores are too high," Johnson says.

"When we look at the overall rating of each category of workers, they’re almost always excellent; we’ve never had anything lower than ‘good,’" she adds. "How do we know what we can improve if they keep telling us that we’re wonderful?"

The agency also has received positive feedback from other indicators of satisfaction from physicians. "We get more calls from physicians telling us we’re doing a great job than we ever get complaints," Johnson says.

Still, the agency won’t be satisfied with its physician survey until the staff has done everything possible to improve it, she says.

Officials with the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, say it’s a red flag when customer satisfaction surveys show 100% satisfaction, because there might be a problem in how the questions are asked.

With this in mind, Huron Valley has formed a committee that meets regularly to discuss the survey. The group analyzes the survey results, writes a quarterly report, and brainstorms about ways to improve its questions. (See Huron Valley quarterly report, p. 113.)

"We can’t be perfect," Johnson says. "So are we asking the right questions? Could we find out the things we need to do to improve if we asked different questions?"

The committee also has combed through other home care organizations’ surveys in a search for more usable questions. So far, Johnson says, none of the referral source surveys they’ve examined have contained questions that are much different from Huron Valley’s survey.

Johnson says the agency wanted to encourage the busy doctors to fill out the survey, so they put it on one page, using only four to five questions. (See Huron Valley’s May referral source survey, p. 114.)

"We began with the premise that physicians are busy and won’t take much time to answer a survey, so we better get what we need on one page or less," Johnson says. "And it should be clear that they could fax it back to us if they wanted to."

The agency has revised the survey each time it’s sent out. But Johnson says they’ve used some of the same questions each time because they need to collect the same data for tracking and looking for trends.

Here’s one question they revised: An important question was asked in an awkward way on the first survey. The agency wanted to know which home care services were the most important to the doctors. So the survey asked them to rank the characteristics that are most important to them, starting with 1, then 2, then 3, and so on.

"We wanted them to tell us what’s most important to them, but when we got the surveys back, we found they ranked all of them as extremely important," Johnson says. The physicians failed to rank one characteristic over another, as the question had asked them to do.

Johnson says the problem was that the physicians didn’t want to say that any of those characteristics were less important to them. They couldn’t decide, for example, between "home care staff are skilled/competent" and "you are contacted if patient’s condition changes."

So the agency changed that question to make it one where the physicians could choose "very important" for each of the characteristics if they wanted to.

The next survey might eliminate that question altogether if it appears that none of the physicians rate any of those characteristics lower than a "very important," Johnson says.

"If all of them are equally important, then maybe we’re beating our heads against the wall trying to get them to differentiate," she says. "It might be like saying, ‘Do you want to be successful or have money?’ and maybe you want both."

A question that has elicited some response is as follows: "Are there ways our agency might improve its services to your or your clients?"

About 90% answered "no," but several wrote down specific changes they’d like to see. One doctor commented that he’d like the agency to stop sending him physician orders to sign, Johnson recalls.

Obviously, the agency can’t stop sending him the orders. However, the staff could do a better job of educating the doctor about why orders are necessary for legal and accrediting requirements, Johnson says. So they followed up the survey response by contacting the physician and explaining why they had to obtain his signature on the orders.