Running a practice
Designing A Consumer Friendly Practice
Linda Mann, MBBS, BSc Med, FRACGP, is a general practitioner, Leichhardt Family Medical Practice, Leichhardt, New South Wales. Dianne Chambers, MBBS, FRACGP, Dip Hyp, Dip Child Health, is a general practitioner, Leichhardt Family Medical Practice, Leichhardt, New South Wales.
Background With the threat of corporate practice looming, smaller private general practices need to define their role in order to attract patients (consumers)and doctors, to build and maintain a successful practice.
Objective To outline various means of instituting a consumer friendly practice.
Discussion Consider what consumers want. Bearing in mind these aims, build the physical aspects of your practice to respond to the needs of consumers, and develop practice activity, philosophy and culture which satisfy the desires of consumers and those of the doctors and staff who work in your practice. Creating a consumer friendly practice attracts patients, Practice Incentive Payments, and prepares for accreditation. By developing such a culture, general practitioners can build, support and maintain the practice style they prefer, even in the face of competition.
General practitioners in the 21st century are facing rapid change. The threat of corporatisation means traditional GPs need to offer more than their big business competitors. They need to maintain their patient numbers by attracting at least as many new patients as those who leave, find satisfaction in the work they do themselves, and make a decent income. Increasingly, through the Practice Incentives Program (PIP) and accreditation, general practices which are consumer friendly are rewarded by government grants, as well as patient and worker satisfaction.
Is a consumer friendly practice possible?
What research says consumers want
Steven and Douglas in Adelaide in 1988 looked at factors relating to architecture, reception, accessibility, quality and communication. They found little evidence of dissatisfaction with regard to quality in healthcare, however, consumers were critical of the mechanics of provision of service. Particular dissatisfaction was expressed with regard to issues of accessibility and communication.1
In the British literature, patients want health care which is:
- available within a time period consistent with clinical need
- appropriate, ie. the best choice of treatment, with the patient sharing the decision
- effective, ie. provided correctly and safely, consistent with current research evidence
- acceptable as judged by the patient or their advocate
- beneficial.2
Australians would add equitable.3 Patients in rural and urban environments deserve access, as do rich, poor, the young and the old. Underlying many of these outcomes is good communication, backed up by courtesy and respect.4
The marketing model
Doctors are professionals for whom medical history, examination, test interpretation and diagnosis underlie standards of care. Consumers cannot easily judge these standards.5 Patients differentiate doctors on the basis of our manner, eye contact, punctuality, location of consulting rooms, attitude of reception staff and other nonmedical aspects (Figure 1).
RACGP standards for general practice
The RACGP standards (which evolved through a process of consultation between the profession and consumers) can form the basis of the consumer friendly practice but to be truly consumer friendly we may need to move beyond these standards.
Incorporating consumer friendly aspects into the architecture of the practice
Architecture can facilitate the improvement in communication and the sharing of decision making which consumers seek.
Designing consulting rooms
Placing the desk against a wall with the doctor and patient on the same side of the table encourages open communication. The presence of a computer screen appears not to daunt the majority of patients. It can be offputting for patients, however, if the doctor has to turn their back to use the computer (Figure 2).
When a curious toddler accidentally opens the surgery door, is the examination couch on view? If so, a curtain, which can be drawn across to provide privacy, is useful, and is a requirement for accreditation.
Soundproofing is essential for consumers’ trust in the confidentiality of the practice. Waiting areas need sufficient ambient noise to mask phone conversations. ‘Corridor consultations’ should be banned from audible spaces: consider instituting a ‘zone of silence’ in your sterilising or storeroom, to emphasise this.
Subscribe to organisations that assist with consumer oriented written material, eg. Diabetes Australia, nutrition fact sheets from a state health department, MASTA, MIMS Assist, drug and alcohol database or the National Heart Foundation.
Designing the waiting room
Reception
Physical layout is important with clear signage, adequate staff and computer screens not visible by anyone but the staff. The reception telephone manner should be helpful to the caller and not audible to those waiting. If this is proving hard to achieve, consider different solutions: another phone line with useful messages on hold; the option for the practice to ring the patient back later; an information kit for patients to limit the need for long explanations about appointments, payment and access to home visits. Some e-health portals are offering connections that permit patients to make their own appointments; if this option is employed it is important to ensure that those patients who do not have access to the internet have equal priority to your appointments.
Consumers appreciate adequate seating, or a place to lie if unwell, a space for children to play where they can be distracted away from unwell adults, comfortable ambient temperature and something to do while they wait. They also do not wish to be infected by attending your waitingroom; patient and receptionist education about separating children and adults with possible infectious diseases helps spread your reputation as a healthy practice.
All of the practice waiting room and its facilities need to be visibly cleaned, tidy and well maintained, including toys that are well chosen for their visual appeal, safety and ability to be kept hygienic.
Patient information
Patients can be informed by posters, books to read, videos to watch, audiotapes to listen to, and pamphlets to keep. Consider a purpose built pamphlet file: many self assemble furniture companies sell inexpensive shelving suitable for this (Figure 3). Noticeboards are expensive to buy ready made but easily constructed from Canite covered in material which is stapled in place and rivetted to the wall. Reception staff can check the currency of notices to maintain relevance. All staff can gather health promotion and community information for these boards from suitable sources: anything from the local paper, to public health messages, to glossy posters.
This form of community networking is another assessment point for accreditation.
Drug companies, educational institutions and libraries offer books, audio tapes, videotapes and CDs suitable for patient education. Set up a lending library: a $5 deposit helps patients remember to bring them back. A card file kept in alphabetical order of the name of the resource, allows recording of the name and phone number of the lender. This allows you to recall precious resources when needed.
Incorporating new technology
Accessibility has ranked highly in all previous consumer surveys and is reflected in the RACGP accreditation standards which require all practices to make provision for after hours care. The imminent availability of online consultations (in an appropriately secure environment), can make us available at patient convenient times but within a doctor determined work framework.
Internet searches are now a reality for a growing proportion of the population. Increasingly doctors are faced with patients bearing large printouts on their illness. Having the internet open on all doctors’ desks facilitates easy patient education. People with specific or unusual conditions may benefit from doctor assisted formal sessions using the internet to search for current information.
Incorporating consumer friendly aspects into the philosophy and culture of the practice
The philosophy of the practice determines what all the workers do, and how the consumers feel they are treated. In a practice with a ‘doctor centred’ or authoritarian culture, decisions are reached by instruction from the doctor, with little flexibility for input from the staff or patients. Many of the features of these practices are for the doctor’s ease. In a ‘patient centred’ practice, decisions may still be reached by the doctor, but their purpose is to enhance the patient/consumer’s experience. This, in turn, enhances the work of the practice, its success, and its viability.
What are the features of the patient centred practice?
Respect
The philosophy of patient centred care is one where the needs of the patient determine the process of the consultation. The patient and doctor together define the parameters of the health care and advice the patient will receive. How is this done?
- Take a full history that includes the issues important to consumers: sex, alternate therapies, acknowledging other practitioners.
- Use neutral language, eg. partner not husband.
- Outline the possible investigations and management strategies; choose the next action together.
- Leave the patient in no doubt about things you feel are important and possibly life affecting, eg. treatment for cancer, but recognise the patient’s right to ignore your good advice (keep plenty of evidence of that good advice, of course).
In a British study of what patients want from doctors, 60% of patients had their own ideas about what was wrong and 42% presented because they had reached the limit of their ability to cope with their problem. Failure to address these issues leads to unsatisfactory consultations for both patient and doctor. Suitable language can allow the patient to declare their problems, and may permit the conclusion of the consultation without misleading diagnoses, tests and treatments.6
Be as good a doctor as you know you are
Patients expect doctors to ask about smoking, alcohol intake, and drug use. They expect us to involve them in available health screens for osteoporosis, diabetes, and cancer. They will thank us if we ask about those deep secrets like domestic violence, impotence, marital difficulties and depression.
Recalls for routine and one-off health promotion
It is now part of the accreditation standards for general practices to provide recalls. This can be done manually but may be time consuming. With increasing use of computers, practices can provide recalls for vaccination (rewarded by PIP) and other areas which have been validated by best health practice, eg. hypertension checks, Pap smears, diabetes recalls etc.
Conclusion
Increasing consumer activism has been a feature of the last part of the 20th century. Consumers demand technical competence but also highly rate quality service and good interpersonal skills.7 They sense a clash between the traditional authority and status of medical practitioners and the broader social changes that have seen customer service and satisfaction become central to so many services in the public and private sector.
The challenge now, is to establish a partnership which will work cooperatively to create the consumer friendly general practice. This will ensure not only our financial viability, but also professionally satisfied doctors and consumers who can take an active role in the maintenance of their own health.
There are good reasons to aim for a consumer friendly practice. Such a practice ensures patient numbers. The surgery characteristics that consumers want are comfortable and attractive to workers. Patient centred consultations produce satisfied patients, and therefore satisfied doctors. And on top of all this, you get paid for it.
References
- Steven I, Douglas R. Dissatisfaction in general practice: What do patients really want? Med J Aust 1988; 148(6):280–282.
- British Medical Association. Association of quality in healthcare, NAHAT. Improving the quality of health care: a partnership agenda. London: Association of Quality in Healthcare, BMA, NAHAT, 1995.
- Mooney G, Wiseman V. Burden of disease and priority setting. Health Econ 2000; 9(5):369–372.
- Bellamy M. Law in practice. Australian Doctor 2000:42.
- Beaton G. Marketing in medical practice. Aust Fam Physician 1987; 16(10):1506–1509.
- McKinley R K, Middleton J F. What do patients want from doctors? Content analysis of written patient agendas for the consultation. Br J Gen Pract 1999; 49(447):796–800.
- Commonwealth Department of Health and Family Services and Consumers Health Forum, 1996.