Anna Runkle Consulting has two branches — Service Revolution for healthcare consulting and Click to Play Media for video and e-learning.  Service Revolution helps healthcare agencies improve clinic performance and the patient experience; we offer telephone audits, onsite evaluation of customer service, training and workshops.  Through Click to Play Media, we also produce high quality video and e-learning for healthcare and the technology sector.

According to the Journal of the American Academy of Physician Assistants:

…nearly 90 million adults have inadequate written health literacy.^1,3 While the average US adult reads below the ninth grade level, 21% of adults read below the sixth grade level.^1,3 Of Medicare enrollees with low health literacy, 42% reported that they could not understand medication directions, 22% did not understand their appointment slips, and 62% could not understand an informed consent form.⁴ 

Little research has focused on numerical (quantitative) health literacy, the ability to make sense of numbers and other mathematical concepts. However, recent studies suggest that poor numerical literacy is significantly more prevalent than poor written literacy because the former affects patients with written literacy and high education level.⁷  

This story in the New York Times about fast-food sandwich shop Pret a Manger reminds us that customer service needs to be a system, and not just a “value.”  Their competitive edge lies in delivering good food quickly with cheerful service — not always easy when employees earn little more than minimum wage.  The restaurant chain looks for cheerfulness when they hire, provides training, and has an ample (but simple) system of rewards to give modest bonuses to individuals and teams based on observed customer service.  The company makes frequent use of secret shoppers, whose feedback is shared with staff and used as a basis for rewards.  Most of their strategies would work well in clinical settings… have a look.

Anna Runkle Consulting/Click to Play Media specializes in making video and e-learning that demonstrates skills for the health care setting.  Many of these works involve clinical scenarios that demonstrate for viewers the communication strategies to open communication with patients, ask good questions, and respond appropriately to answers.  Click here to see some of the training videos we made for Futures Without Violence, whose goal is to train providers to detect and address two complex issues — domestic violence and reproductive coercion.

It is clear, however, that mastery over clinic performance is the most reliable means that community clinics can use, not only for succesful adaptation to pressure and change in the industry, but for innovation. Effectively managing clinic performance helps leaders to conserve energy for creative leadership — less firefighting and more piloting.  Less cost cutting and more revenue production. It also builds technical skills for leading change — analysis, measurement, intervention, evaluation.
The Key Performance Indicators ought to be a small handful — maybe three to ten — that provide a reliable read on clinic success.  They ought to be specific, measurable and significant in terms of their impact on overall agency health and quality of care.   They also should be actionable; that is, you should confine your measurement to problems you are willing to solve.  Finally, it is best if the indicator does not depend on self-reporting, which is prone to error as well as rationalization. Indicators that can be validated externally can be more reliably used to act decisively and advocate effectively. Of course, no agency can perfectly control all KPIs.  Some have dips and valleys because of population characteristics, funding changes, and other market factors.

I’m interested to hear what your agency is using to evaluate clinic performance — what’s working well, what’s not working so well, and how you might design the perfect measurement program.  And, what indicators are you using?  Here are a few that I tend to recommend to consulting clients, because they meet the above criteria:

1. Days booked out (timely appointments are about to become a KPI for private practices, as required by the CA DMHC_.

2. RVU* (relative value unit) per clinician hour

3. Billed revenue per RVU

3. Contraceptive method mix (this is a proxy for the overall qualtiy of preventive reproductive health care)

4. Overall customer service rating, using telephone auditing (recorded secret shopper calls)

5. Total time in-clinic for a given appointment

*RVUs, or relative value units, function as a proxy for health care output — the amount of health care “bang” for the buck (you can replace “buck” with input resources, clinician hour, visit, or clinic day). They are updated each year to reflect the provider time, overhead (including staff time) and malpractice insurance cost involved in delivering a billable health care event. There are also multipliers used to adjust resource estimates according to varying costs geographically. RVUs are a more accurate measurement of productivity than visits, per se, which vary greatly in terms of complexity and resources required. RVUs were established (and are adjusted annually) by Medicaid, but used throughout the healthcare industry as an aide in setting reimbursement and provider pay rates and measuring productivity.  RVUs are calculated by most practice management systems, but can be calculated manually when a PMS is unavailable.

The New York Times last week ran a very popular article criticizing (nay, SLAMMING) the misuse and overuse of PowerPoint for presenting information — “We Have Met the Enemy and It is PowerPoint,” which cited an article in The Armed Forces Journal, “Dumb Dumb Bullets” by A.X. Hammes (OK, it was Hammes who slammed), which addressed the abbreviated thinking and meaningless visuals that have replaced the more careful, clear, complete thoughts that were required back in the days when we had to just get up and speak to a group.

There are many fine points in both articles, and here’s one I’d like to add: Try giving up PowerPoint for your next presentation.  It’s kind of like asking your kids to give up television for a week.  It takes some adjustment, and you might feel a bit stressed and worried how you’ll keep everyone entertained.  Instead, keep the lights on, stand close to your audience and walk among them.  Look into their eyes and use your voice, body and facial expression to animate what you are saying, and to add meaning and impact to your words.  You will probably find you’ll have to work harder to make clear points, but your audience will be far more engaged, and more likely to interact with you, retain the information, and integrate it into their work.

1. There is no substitute for being in the clinic, and spending time watching and listening as people greet, schedule, screen, educate, examine, touch, counsel and inform patients.  It’s especially helpful to see how they handle patients who are stressed, hurried, angry, emotional, non-compliant, abusive or receiving bad news. It’s equally important to see how they handle patients who are receiving good news, and who are polite, complimentary, and friendly.
2. The fastest and least expensive way to get a read on customer service is a phone audit, particularly in clinics that answer their own phones.  What you hear on the phone is generally a reflection of what goes on in the clinic. Most phone audits reveal a little bit of rudeness, a little bit of misinformation, and a good deal of low energy and apathy.  
3. The only way to help people learn from phone audits is to record the calls.  This way staff can learn what works and doesn’t work.  Plus, it is the only way many people will believe that problems are really happening.  Recording calls is legal in all states, though some require that both parties be notified at some time prior to recording. 
4. Secret shoppers who come to clinics for services are extremely useful, but expensive compared to calls (my consulting firm does calls for about $35, and visits start at $100).
5. The single biggest factor that influences the quality of customer service is the manager.  A manager can focus on customer service and gradually improve it.  On the other hand, the loss of a good manager can immediately damage it.
6. All managers and staff need indicators they can read, understand and use as the basis for action. Spreadsheets seldom work for this; easy-to-visualize charts are better.  A manager working by herself can only do so much.  A cross-functional team that meets weekly can do much more.
7. Customer service can’t be learned in a single workshop.  Workshops can introduce concepts, but managers must set standards and supervise to the standards.  Either staff are meeting or not meeting the standards; change happens quickly when everyone is clear when standards are met, and are acknowledged for it.
8. Very few clinics have clear and measurable customer service standards.  Things like “excellent service” is not a measurable standard.  “Patient-centered care” is not a measurable standard.  Ensuring that every patient is greeted when s/he enters the lobby is a measurable standard.  Booking patients within 72 hours of their call is a measurable standard.
9. Customer service is not just about about customers, and it’s not just about service.  The biggest beneficiaries of improved customer service are often the staff, who often suffer stressful days full of angry interactions when they lack the training and systems to serve customers well.  Strong customer service grows from effective management.  It results in a more productive, happy and effective workplace.
10. Good customer service functions as an indicator of effective overall management. Like good management, it is not an optional add-on to be eliminated during lean times. It is an essential component of a stable health care setting, with many benefits for patients as well.