MEMBER SATISFACTION

Reducing Complaints Through Improved Communication

What can a managed care plan do when members complain about the quality of care received from their doctors? This plan set about under-standing how members perceive quality of care, and designed comprehensive education programs to improve that perception.

With a computerized system to log and code member complaints, this plan had the ability to review complaint categories and free-text narrative accompanying each complaint. As early as 1994, the plan discovered that it had an unacceptably high rate of complaints about quality of care.

The plan became concerned that high levels of complaints would make it difficult to retain members. It felt that many unhappy members don't complain, but simply leave the plan. The plan set about improving its understanding of its members' complaints, and how its network practitioners, and their offices, were communicating with patients.

The plan targeted all commercial and Medicare members (and the primary care practitioners who served them) for this activity.

The plan used its computerized complaint system to track complaints due to quality of care. It reported these complaint rates per 1,000 member/months for both Medicare and commercial populations.

Baseline measurement, using 1994 data on this measure, actually preceded the formal QIA time period. The plan began the formal activity in 1995, and added an additional measure-complaints due to practitioner/office staff attitudes. Once again, the plan reported it per 1,000 member/months for both commercial and Medicare products.

The plan's Quality Improvement committee set goals based on historical trends, and on the notion that efforts toward the improvement goals should represent a "stretch" for the organization.

The plan conducted focus groups with commercial and Medicare members to better understand the reasons for these types of complaints. It became apparent that patients often judged quality of care by the quality of their health care providers' communication.

Few members in the focus groups professed the ability to judge a doctor's clinical skill or knowledge. Instead, they relied on identifying poor quality with doctor behaviors, such as not making eye contact, not sitting down, or not seeming to listen.

The plan identified its providers' poor verbal and non verbal communications skills as the root cause of many member quality of care complaints.

Analysis of narratives in the complaint log showed that attitude complaints about office staff were often about rude, uncaring communication (although a significant number were about the plan or managed care in general).

GOOD DOCTOR-PATIENT COMMUNICATION Some experts maintain that the number one reason that patients switch doctors is that they don't feel like the doctor is listening to them, or showing a caring attitude. [1] One of the factors making patients feel this way is the doctor's handling of the visit. A patient starts talking about his/her problems and, 18 seconds later, the doctor interrupts with a series of rapid-fire questions. [2] Worsening the situation is the low likelihood that the patient actually began with his/her most important concern. But if a doctor begins with an open-ended question and doesn't interrupt, patients only speak for a couple of minutes, and are more candid about what's bothering them. [3]

The plan identified primary care offices with both high and low complaint rates. A plan observer visited these offices and shadowed the primary care physicians. Personnel at offices with low complaint rates were found to be more skilled at active listening, reading body language, and demonstrating sensitivity toward their patients. They tended to have a good understanding of managed care. In offices with high complaint rates, staff and providers seemed harried, tending to rush the patient through the interaction. Personnel were often unhappy with managed care. Providers would tell their patients that they couldn't do something because of the plan, or because of managed care.

Plan staff also reviewed the results of member surveys completed by patients after their PCP visits.

The plan identified the following barriers to be addressed:

• Poor communications training or skills
• No time set aside for training of practitioners and their staffs
• Practitioners' aversion to dealing with upset or angry patients
• Practitioners blaming managed care for their own behaviors
• Feeling by member of being rushed and ignored
• Aging patients requiring specialized attention

The plan decided to implement a major training effort aimed at improving the communication skills of the practitioners and their office staffs.

The initiative was planned and carried out by the lead trainer and the director of the training and development department. The provider relations department recruited PCP offices to participate in a pilot program.

The trainers considered techniques that would ensure a high level of participant interaction. These included limiting the training group to fewer than 25 members and avoiding lectures, instead focusing on experiential exercises. They kept the training fast-paced and fun. To minimize distractions, programs were held off-site.

PARTICIPATION: THE KEY INGREDIENT The plan notes that the ones primarily responsible for the program's success were class participants. Practitioners, their staff, and plan staff from all departments eagerly attended classes throughout the plan's service area. Office staff were pleased with the program, and often urged their practitioners to attend. Word-of-mouth proved to be very effective in selling the program.

The health plan trainers initially piloted a half-day program on communication. This quickly became a full-day program. It focused on active listening, nonverbal communication, vocal inflection, assertiveness and techniques for dealing with upset people. The program was opened to all who wished to attend, and offered throughout the service area.

The health plan trainers then designed a second, half-day program, in sensitivity toward seniors. Participants experienced firsthand what it felt like to be a senior. They viewed a video illustrating how the world sounds to a senior with high-frequency hearing loss; they wore glasses that clouded their vision, taped fingers together to simulate arthritis, and put uncooked macaroni in their shoes to make walking difficult.

The plan developed and distributed a training schedule that described its program offerings. (A copy is included in QP Tool .)

The first remeasurement was based on 1996 data:

Small declines in complaint rates for commercial members were not statistically significant. The decline in quality of care complaints from Medicare members was significant (chi square of 77.4, p<.0001) The decline in attitude complaints by seniors was also significant (chi square of 18.9, p<.0001)

The plan decided that the programs were having an impact and needed to be expanded. Two additional trainers were hired. The plan began to offer CE units to nurses attending the programs. Hospitals began to send staff to the programs.

Providers with high complaint rates and disenrollment levels were targeted with special invitations to hold programs at their convenience, including on weekends.

The plan developed two new programs. The first was a half-day program on telephone skills. The second was a basic program on managed care designed for new PCPs and their staffs.

The second remeasurement used data from 1997:

Both groups of enrollees had statistically significant decreases in complaints related to quality of care (Medicare chi square of 65.8, p<.0001; commercial chi square 168.2, p<.000l). Attitude complaints from Medicare members were statistically no different than the previous year's; commercial attitude complaints decreased significantly (chi square 13.1, p=.0003).

The plan continued to offer the programs to practitioner and plan staff on a regular basis, and at special times as requested.

Remeasurement number three used January-June 1998 data:

All attitude and quality of care complaint rates declined significantly in the first six months of 1998, as compared to the previous year. The overall trend from baseline through mid-1998 showed significant improvement by weighted least square regression (a sample chart is included in QP Tool ).

The trainers believe that the plan has achieved a closer relationship with its practitioners by providing a service that met a clearly felt need. Both immediate and one-month post-course evaluations remain extremely positive. Comments from participants report incorporating learned skills into their daily work.

The plan continues to offer these programs. Practitioners and their staff are eager to improve their communication skills. Offices report less employee turnover and burnout. The classes remain so popular that practices have closed their offices for a whole day, so that the entire staff can attend.

The plan addressed a seemingly impossible problem - the perception of bad attitude and poor quality of care among practitioners and office staff. By getting its network doctors and personnel out of their offices, and learning new skills, it addressed it in a way that was not only unique and interesting, but also very effective in achieving meaningful improvement.

[1] - Boodman, SG, ''Divorcing Your Doctor,'' Washington Post, 25 March 2000, 12(Z).

[2] - Ibid.

[3] - Ibid.