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Fall 2006

Customer Service - Get It Yourself!

Jerry Ippolito
Vice President & Principal, The Surgery Management Improvement Group, Inc.

Customer Service - Get it yourself!

That was the headline in last Sunday's paper here in my Southwest Florida community. This community is burgeoning with population growth and still recovering from last year's hurricanes. There are not enough workers to meet the demand and any breathing creature can obtain a job in the service and construction industry - but what is the work ethic and professionalism of that worker? Customer service - let's look at our everyday lives. Whether booking a hotel reservation, questioning a bill, trying to get the TV-cable repaired, or working with your bank - just think of how difficult it is to speak to a person - typically the "customer" the guy who's spending the money with the option of taking business elsewhere, is directed to voice-mail; hears, "push one for this" ;"push two for that" ; or best yet, must pay additional fees to speak to a person - How Do You Feel, When You the Customer are Treated That Way?

In healthcare we speak a lot about "the customer and providing customer service" . Several of my hospital clients have "Customer Relations Specialists" - I think these individuals are intended to assist patients with service related issues, however I've never really been able to understand what these specialists really do. In other instances, my hospital clients have "Physician Liaisons" - these individuals are intended to assist physicians based at a hospital with service related issues. Humorous as it may seem, as an anesthesiologist have you ever been approached by the Physician Liaison at your hospital and asked,"how are we doing" - probably not. However in my world of Operating Room Management Consulting I do encourage OR Team Leaders and Directors of Surgical Services to take on that duty -"how are we doing?" . The phenomena however is that we talk a lot about customer service and we have customer service specialists of every species, BUT HAVE WE DEFINED WHO THE CUSTOMER IS? According to Webster the customer is:

    1. one who purchases a commodity;
    2. one with expectations of outcomes.

Some years ago I participated in a CQI (Continuous Quality Improvement) program where the second definition was more commonly used; in fact the second definition, in my mind, is the most appropriate. We all have needs and rely on performance and fulfillment of expectations by others - WE ARE ALL EACH OTHER'S CUSTOMERS.

In the world of the operating room we typically regard the surgeon as the customer. Ironic as it is, we seldom consider the patient first. As a consultant I have the opportunity to work with several dozen hospitals each year in many communities around the country - indeed the patient is the primary customer (even more ironic in today's world is that the payor is beginning to usurp this position). As I sit in restaurants, ride on planes, read local papers I'll continuously hear / read about residents' perceptions of the local hospital. I've had the honor of working with several very prestigious community medical centers around the country; if physicians are not on staff at these centers, they can not build or sustain a practice - if they are not on staff at these centers,they are not considered quality doctors - THE PATIENT IS HIGHLY SELECTIVE, and rightfully so!

In the world of OR we often speak of the three or four legged stool - the four customers; the four constituencies with expectations; even here we forget about the patient - aren't there really at least five customers:

      1. Patient - Expectations of: Quality care; Hospitality; Affordability; Accessibility
      2. Hospital Administration - Expectations of: Increased business; Increased Margins; Decreased Costs; Maximized utilization of resources
      3. OR Staff / Nursing - Expectations of: Ability to deliver quality patient care; Competitive compensation; Reasonable working conditions; Job satisfaction; Reliable and predictable workschedules
      4. Surgeons - Expectations of: Quality patient care; Sufficient OR access to meet practice needs; Maximized / efficient use of time; Experienced OR staff who can anticipate case needs; Equipment and technology meeting procedural needs; Ability to generate a livelihood comparable to similar specialists
      5. Anesthesiologists - Expectations of: Quality patient care; Optimized utilization of time; Competitive compensation and lifestyle; Predictability of schedules.

If any one customer's or constituent's expectations are fully satisfied (the 100 percent level) then fulfillment of other's expectations will suffer.

I hope we're now all agreed that the patient belongs in the center of our universe as professionals in the field of healthcare. Let's move on to the "nuts-and-bolts" of developing customer satisfaction in the OR. Let's first talk about the surgeon as we always hear that the surgeon is the customer. Typically the surgeon (or medical staff in general) wants to be regarded as a patron or customer of the hospital; the customer maintains the option to shop elsewhere. The hospital-business will not survive without the physician (and patient) customer(s). As in the retail environment the physician-customer maintains an expectation that the vendor (hospital) delivers a quality product. However, unique to the hospital setting is that the product is truly a service vs. a tangible product; physician-customers place primary emphasis on the hospital meeting their service oriented expectations. Physician-customers typically "Want what they want, when they want it" . The physician customer typically forgets that even in the most service oriented, traditional environment (whether Ritz Carlton, Nieman Marcus or Lexus dealership) hours of operation, dress codes, pricing strategies, rules of conduct, (etc.) exist and are required to effectively and reliably meet the majority of customers' expectations. Too frequently physicians / surgeons expect the administrative team (and anesthesiology) to meet 100 percent of expectations 100 percent of the time on terms established by the physician-customer at any given point in time. This mind-set, if allowed, diminishes the ability to optimize service to the other customers (patients, nursing, anesthesiology, administration). Compromise is key.

Now what you've been waiting for - does anesthesiology ever get to be the customer and what role does anesthesiology play in meeting customer service / satisfaction requirements? Surgeons will gravitate to those hospitals and ASCs where a superior level of anesthesiology care is provided - where there is choice. Patients are generally unaware of the level of care / expertise provided by the anesthesia service and really don't make decisions based on this factor. Doctors, I know this is going to hurt, but I now have to drop the bomb - in my nearly thirty years in healthcare and fourteen years in consulting, I can not site an instance where an anesthesiologist referred a case to a hospital (pain management or a personal referral aside). Indeed, quality anesthesiologists and CRNA (AA's) are in short supply these days and do have numerous job / practice opportunities, but typically anesthesiology's decision of where to "perform / take a case: requires a career and geographic move - very different from the surgeon's opportunities. Doctors, we just have to "bite-the-bullet" and deal with reality. I spend a sizeable amount of my time in consulting and interviewing anesthesiologists around the country and all too frequently I'll hear: "My income is decreasing because they (meaning hospital administration) have lost the outpatient business" . In polite terms I'll ask, "What role did anesthesiology play in retaining that business?" Generally I'll continue with the anesthesiologist and ask, "Do you consider yourself a consulting specialist? " Almost universally the anesthesiologist responds "Yes" - well then, don't consulting specialists need to garner referrals; develop and protect referral sources? It then begins to sink in. In the old days and still in some pockets of the country, anesthesiologists teamed up with surgeons and followed the surgeon all around town providing anesthesia for the surgeon's case. The surgeon was treated as a customer or client of the anesthesiologist; the anesthesiologist was expected to provide a certain level of service (I know I'm rubbing salt in the wound - sorry). Today the model has greatly changed and rightfully so due to the economics of healthcare - one surgeon's practice can not support an anesthesiologist at today's reimbursement levels. So then, the anesthesiologist, all the more, needs to expand and further develop the practice base - the anesthesiologist requires more clients / customers to generate the expected livelihood; the anesthesiologist needs to: "Market to the Customer; Build the Business".

As we wrap this up, let's focus on anesthesia's role in customer service in the operating room as well as anesthesia's position as a customer. In general, customers' expectations, regardless of who the customer is, will not be met unless expectations are reasonable and clearly defined. Most frequently for anesthesia this is defining how many sites are staffed by hour of day and day of week; this CAN NOT be a moving target if customer service is to be effectively delivered. Only as a few examples, as a customer, anesthesia should be able to rely on:

        • Development of clearly defined and agreed to expectations with regard to sites staffed;
        • Competitive compensation and lifestyle for services rendered delivering to expectations (potentially requiring a hospital stipend);
        • An OR committee (or governance body) having developed effective scheduling policies and procedures and further, consistently enforcing them;
        • Surgeons' offices effectively communicating with OR scheduling;
        • Surgeons effectively communicating with anesthesia with regard to difficult cases or sick patients;
        • Nursing effectively implementing preadmission screening protocols that have been developed jointly with anesthesia;
        • Charts being complete on the day of surgery;
        • Patients being appropriately prepared for surgery in either a Day-surgery unit or on the hospital floor;
        • Ability to transport the patient to the OR in a timely manner in order to have on-time case starts;
        • Surgeons reporting to the OR on time for on-time case starts;
        • Experienced OR staff and appropriately set-up cases in order to reduce case times;
        • Experienced charge nurses working with anesthesia to run the day's schedule;
        • Experienced PACU staff who can function with relative independence;
        • Lots of other stuff...

In providing customer services anesthesia should be expected to:

          • Be current in state-of-the art anesthesia care with an emphasis on ambulatory anesthesia;
          • Maintain reasonable flexibility with regard to agreed expectations - maintain an attitude of meeting or exceeding expectations;
          • Assure consistent and reliable staffing for all anesthesia sites agreed to;
          • Collaborate with nursing to develop state-of-the-art preadmission guidelines; agree as a group to established guidelines;
          • Screen all ASA III and above patients and visit with all inpatients prior to the day of surgery;
          • Develop processes to administer anesthesia consults for the preadmission unit;
          • Call patients on the evening prior to surgery;
          • Be as familiar as possible with patients' conditions prior to the day of surgery;
          • Review patient charts at least the day prior to surgery;
          • Proactively work with nursing in schedule planning and management;
          • Begin reviewing the schedule with nursing several days prior to surgery;
          • Facilitate getting patients into the OR for on-time case starts;
          • Facilitate expediting turnaround time;
          • Maintain an effective medical direction model where CRNA direction is based on case complexity, patient acuity and CRNA skill level;
          • Be promptly available to CRNAs during on-going cases;
          • Be promptly available to CRNAs cases to expedite induction and emergence;
          • Develop a staffing model and service agreement model whereby anesthesia staffing requirements of OR-peripheral sites does not disrupt OR staffing;
          • Develop a Q/I and education model for all anesthesiologists, CRNAs and hospital staff (RNs; RTs) where appropriate;
          • Assign lead individuals to foster skills and business development in key services such as cardiac / vascular,OB, ambulatory, pain (potentially neuro, trauma, pediatrics);
          • Play a key role in developing and sustaining YOUR OWN BUSINESS by focusing on what is required to develop a marketable and financially viable surgical program with increasing case volume;
          • Focus on delivering the highest level of patient care with respect for the patient's time; provide hospitality; Focus on defining expectations and then exceeding those client / customer expectations and your business / anesthesia practice will flourish(1).

(1)Depending on expectations, payor mix and OR efficiencies / case times there may always be a need to approach hospital administration for a subsidy payment to deliver on expectations.