Measuring and Enhancing Patient Satisfaction in an Optometry Practice
Gilbert Blanks, OD, MS

To grow and prosper, health care providers must satisfy their patients; offering superior customer service is a prerequisite.1 Satisfied patients are more likely to return to the practice for goods and services. They are more likely to refer their friends and relatives to the practice, and they are more likely to follow treatment recommendations.2,3 Patients who will probably return are considered loyal, and they are a valuable resource for any practice.4 Providing quality services to them is also efficient because tasks needn't be redone or modified to fulfill patient expectations.

To measure patient satisfaction in an optometry practice, service and product quality must be carefully evaluated. Certainly, appropriate health care is the desired outcome; however, that issue can become clouded in an optometry office. As Rosenthal and Soroka5 point out, "[T]he cosmetic aspect of the end product (contact lenses, frames and tinted lenses) rather than the professional services is too often the focus of attention." This doesn't mean patient satisfaction should not be analyzed. Rather, it means attention to various aspects of the service encounter may need to be weighted and evaluated differently.

Essentials of Service
A close analysis of the reasons behind measurement of patient satisfaction can be divided into the three essentials of customer service: systems, strategies, and employees.

  • Systems include implementation of new policies or elimination of adverse policies affecting patient satisfaction. The facility's physical layout and the amount of resources allocated to it can affect patient satisfaction.
  • Strategies begin with customer input, which helps the practice determine patient needs, wants, and expectations. Your patients' comments and suggestions can guide the planning of organizational resources and efforts to meet their expectations. Marketing efforts can also be guided by this feedback.
  • Measurement of patient satisfaction can also reveal information about employee performance. It can guide future training efforts or help you evaluate ongoing employee training. In certain cases, performance reviews and employee raises can be influenced by patient feedback.
About Managed Care
With the advent of managed care, providers must be even more sensitive to the satisfaction of their patients. Managed care organizations often grant or discontinue panel status to providers based on the level of patient satisfaction with the provider.5 The impact satisfaction has on a patient's intention to return to your practice makes increasing that level important as it can directly affect the practice's net income.

Some providers may consider managed care patients as a "captured" patient base. They may consider that meeting technical quality standards in a cost-effective manner is enough to satisfy managed care standards. Yet, patient satisfaction involves more than this, and it affects who remains on a panel of providers. Managed care organizations use complaint hotlines and satisfaction surveys to ensure their patient members are satisfied with the quality of the health care they are receiving. Therefore, a provider who wants to grow a practice must continue to satisfy the majority of patients (managed care or not) to ensure loyalty and word-of-mouth referrals.

Satisfaction Meets Expectations
Satisfaction has been defined as the customer's perception that his or her expectations have been met or surpassed.7 Patient expectations can be influenced by several factors even before the service encounter. It is up to the provider to exceed those expectations or impart more realistic ones.

Expectations have been defined as predictions made by consumers about what is likely to happen during an impending transaction or exchange.8 There is frequently a gap between what the patient expects and what services are offered. Narrowing this gap results in greater satisfaction.

Patient satisfaction with care and the quality of care are not necessarily the same. John9 makes a distinction:
  • Medical needs are the provider's technical skills used to treat the patient's illness.
  • The psychosocial aspect meets the patient's personal needs of how the medical expertise is delivered in the treatment of the illness.
According to John, these are met by technical dimensions (provider skills in diagnosis and treatment) and subjective dimensions (meeting psychosocial needs).

Babakus and Mangold also differentiate between technical quality and functional quality. They describe technical quality as the accuracy of diagnoses and procedures, a clinical pathways type of quality. Functional quality is the manner of the personal interaction in which the services are delivered to the patient. Although technical services meet high quality standards, the encounter may still not meet the patient's expectations. A distinction must be made between health care quality and consumer satisfaction. Although intertwined, these two elements are not the same.

The Cost of Poor Service
Giving poor service can be expensive for any practice in terms of lost revenue, lost opportunity, and customer replacement costs. When a patient's expectations are not met because of poor service, that patient will likely obtain future services elsewhere, resulting in lost revenue. This also results in the lost opportunity for the patient to refer friends and relatives, resulting in a loss of more revenue.

Unsatisfied people will tell 9 to 10 other people about their experience, making their dissatisfaction exponential.11 It is more expensive to acquire new patients than to have established patients return. It has been estimated that it is five times more expensive to attract new clientele than to keep previous customers.12 A small percentage of patients who are dissatisfied will complain. Unless steps are taken to uncover their dissatisfaction, those patients will simply go elsewhere.

To attach a dollar figure to poor service quality, take the percentage of dissatisfied customers and multiply it by the total number of customers per year times the average dollars spent. For example, use the national average for patient visits to optometry offices13 and the average dollar value spent: 10% dissatisfied 33,000 patients a year 3 $175.00/patient 5 $52,500. This is a conservative estimate of income lost in 1 year because the practice did not meet patient expectations, causing dissatisfaction. That's a large loss even when 90% of the practice's patients are satisfied.

Measuring Satisfaction
Thus, patient satisfaction is a valuable resource, one you must approach from two perspectives: (1) measuring it and (2) increasing it in an efficient, cost-effective manner. Simply executing an appropriate measurement survey is not enough to ensure greater business success.14 The information found must be used to implement changes that will increase satisfaction.

The method of measurement must be valid and reliable. Its ease of use is also important for both provider and consumer. In addition, the method must be inexpensive and effective. And, it actually has to measure the consumer's perception of satisfaction.

There are numerous methods of measuring satisfaction. Internal measures of quality in health care, such as adherence to treatment standards, can be used but may not relate to the patient's actual satisfaction with the encounter. Outcomes measures can also be used, but they don't usually evaluate efficiency and the patient's contentment with the treatment process.

Many patients cannot assess technical competence, so they use other, nontechnical characteristics to evaluate service quality.15 Contextual factors such as staff friendliness and treatment explanations, along with "atmospherics" (appearance of surroundings), are often used by consumers to judge satisfaction. Direct collection of data from patients can be gathered by use of in-office questionnaires, surveys mailed after the visit, telephone surveys, focus groups, or interviews.

Analyses of data-collection methods show telephone surveys are expensive and time consuming. Although this method has the advantage of garnering additional information by the use of follow-up, probing questions to uncover hidden attitudes, this must be done by a well-trained interviewer.

Focus groups can be even more expensive and require a large amount of data that can be condensed into usable results. Unless many patient interviews are conducted by a trained researcher, there can be sampling errors from limited feedback.

Mail surveys after the patient visit have the advantages of anonymity, ease of implementation, and relatively low cost. In addition, you can send modified surveys to different patient groups (i.e., contact lens versus eyeglass wearers), yielding more specific information. If the survey instrument is constructed properly and used with an appropriate sample, the information gathered can be invaluable.

Survey Construction
For most optometric practices, follow-up written surveys are likely the method of choice because they are easy, inexpensive, and not excessively time consuming. From a study conducted in 1988, Parasuraman and coauthors1 developed SERVQUAL, a multiple-item scale that uses a rough framework for survey questions. Five dimensions are included: tangibles, reliability, responsiveness, assurance, and empathy. This model equates satisfaction with differences between performance and expectations, what the authors call the "gap theory." Vigorous testing has shown the instrument's reliability and validity.

There is great discussion in the literature about the distinction between quality and satisfaction.16 Most controversy stems from whether expectations are truly needed to evaluate satisfaction. Cronin and Taylor17 are great proponents of the concept that expectations are not necessary to measure service quality. They don't, however, disagree with the specific questions used in the SERVQUAL, which has been used by other researchers.

Parasuraman and coauthors1 point out that appropriate adaptation of their instrument may be desirable for a particular service business. By using this framework, construct validity in the survey's design is ensured.

Questions and formats used in other surveys, as well as the types of information used by managed care organizations, have been evaluated in the literature.5 Input from all appropriate stakeholders (e.g., vendors, employees, and colleagues) can help guarantee content validity.

Survey reliability refers to the amount of variable errors (differing with each respondent) contained in the questionnaire.19 Keeping the questionnaire short, with straightforward wording, helps keep responses consistent. Statistical analysis of the results can provide a reliability measure by estimating the amount of error. The responses for each question can also be analyzed for internal consistency.20 Using the same survey on an ongoing basis helps a practice confirm the instrument's reliability.

Five-point scales have been shown to discriminate response levels very well. This is in contrast to simple "agree" or "disagree" responses or more numerous response options, such as 7- and 10-point scales. In a literature review of service quality and patient satisfaction, Taylor21 found that most research uses surveys with a 5-point scale. Ratings based on "excellent" to "poor" have been shown to be more accurate in differentiating levels of satisfaction.22

The order of questions should follow the chronological order of the service visit. The questions' wording should be neutral. Positively or negatively worded statements can affect the responses.17 Demographic information should also be included to help classify respondents. Different customer groups are more responsive to different aspects of the service offerings.

Figure 1 shows an example of a mail survey for an optometry practice. Using the SERVQUAL dimensions, the questions cover the following: tangibles (physical facilities), reliability (dependability and accuracy), responsiveness (willingness to help, prompt service), assurance (knowledge of employees), and empathy (caring, individualized attention). Question 1 relates to tangibles, questions 2 and 10 to reliability, questions 6 and 9 to responsiveness, and questions 3, 4, and 7 to assurance. Parasuraman and coauthors1 found reliability to be the most critical dimension and empathy the least. However, this may be different in health care organizations. The question of overall satisfaction and the patient's intention to return are the most important and should show some relationship to the scores of the other questions.

Survey Analysis: Increasing Patient Satisfaction
After a reliable instrument has been devised as a mail survey, your next step is to use the survey to increase patient satisfaction in an efficient, cost-effective manner. First, look carefully at survey questions that yield a consistently low score. These should be regarded as suggestions for improving service.6 Now that a problem in patient satisfaction has been uncovered, a plan to fix the problem should be devised and implemented. This will close the gap between patient expectations and the services offered, increasing satisfaction.

The survey can also be used to categorize patients into perceived quality segments.1 Using the demographic profiles can show whether different groups (e.g., age, sex) perceive the services offered differently. For example, male respondents could be more sensitive to certain aspects of this survey than female respondents. This information could be used to direct resources within the practice to satisfy certain customers in specific ways. Employees should be aware of needs of different patients based on their demographic profile. Attention can be given to these during the service encounter.

The survey results should be considered in respect to the three essentials of customer service: systems, strategies, and employees.
  • Systems could be evaluated by the patient responses to question1, the physical appearance of the office. Dissatisfied responses would indicate a need to upgrade the facility. The physical environment has been shown to be a surrogate to evaluate quality.24 If patients show dissatisfaction with question 2, you should consider expanded hours or increased staffing to improve capacity.
  • In the initial formation of strategic goals, input is gathered from the external environment, the internal environment, and all relevant stakeholders. The needs and desires of the customers should be taken into consideration. Strategic goals that meet the needs of the organization's clientele will be the most successful in adding value to the organization. For example, dissatisfied responses to question9 would indicate a need for shortened delivery time. This could be accomplished in many ways, as long as they meet your customers' desires.
  • At an employee's initial orientation, stress that service quality is an organizational priority and will be evaluated by the ongoing use of patient satisfaction surveys. The perfect time to convey the organization's attitude toward patient satisfaction performance is when employees first start their job.25 Cultivating a corporate culture of patient satisfaction starts at the employee orientation and continues with training, staff meetings, and performance appraisals. When an area of deficiency has been identified through a survey, employees can be encouraged to improve in that area. Questions 3 and 4 deal directly with employee performance and should be looked at critically by management.
Another use of patient satisfaction surveys is in the area of total quality management (TQM). Feedback from customers is critical to the continuous improvement of quality and processes to satisfy customer needs.26 It demands that change be based on the customers' needs, not the provider's values. As TQM is usually an ongoing process, it requires continuous collection of information to feed into the quality improvement system.

Figure 1. Sample Patient Survey.

Patient Survey

Please tell us whether you are male or female ___________________________ and your age ______________.

For each question, circle the appropriate number that indicates your opinion.

5 = excellent; 4 = good; 3 = fair; 2 = not so good; 1 = poor


Be Proactive
Responses to reported areas of dissatisfaction are important, but proactive moves to increase satisfaction can be just as important. Increased satisfaction will lead to stronger intentions to return to the practice and stronger recommendations to friends and family to use that practice. When you dispense eyeglasses, most people do not expect to receive free eyeglass cleaner and an explanation on how to care for their new eyewear. This additional benefit will exceed their expectations, filling any gaps and resulting in satisfaction.

Ongoing communication with patients will encourage them to return to the practice.27 For example, thank-you letters sent to patients after their visit could influence their perception of the practice and enhance their future level of satisfaction. Longer term perceptions of the practice could be influenced by sending patients newsletters. Eyecare is not a common purchase; therefore, a patient's attachment to a practice can dwindle over time. Encouraging patients, on a regular basis, to return to the practice galvanizes loyalty into positive word-of-mouth.

Strategic moves can be evaluated by survey results. After new policies are implemented (e.g., eyeglass cleaner, thank-you notes, newsletters), compare current survey results with previous ones to determine a specific strategy's effectiveness. Ongoing use of surveys on a scheduled basis can reveal trends that demand the organization's attention.

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