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February 2007

Practice Perfect: Business Operations
How to Increase Word-of-Mouth Referrals
By Derek A. Preece, MBA

In the 17 years that I have been conducting patient-satisfaction surveys, the practices that score extremely highly have all had long-term financial success. Some of them may have short-term problems —when, for instance, a biller quits—but they bounce back because they know how to keep patients happy.

Patients want competence and a caring attitude. In my experience, everything that a patient looks for in a practice falls into those two categories. When patients give a practice high marks for both its competence and its caring attitude, they are likely to become “missionary referrers” who actively recommend the practice to their friends, neighbors and workmates. When a practice scores high for competence but low for its caring attitude, its patients will return for specialty care but will also tend to be “negative referrers” and will go elsewhere for routine care. Conversely, when a practice scores low for competence but high for its caring attitude, patients tend to be “casual referrers” for routine care, but they may withhold their recommendation for nonroutine care. And when a practice scores low on both counts, that’s when lawsuits get filed.

What influences patients’ perceptions of your practice? Your practice has four opportunities to demonstrate competence and a caring attitude:

1. The physician-patient relationship. This is paramount. Patients may be willing to travel long distances, change health care plans and even shrug off the indifference of office staff, provided that they perceive their physician to be highly caring and competent.

And how do patients evaluate a physician’s competence? For instance, when somebody says, “My doctor is terrific; the operation went perfectly,” how does he know whether the physician’s performance was above or below par? It is unlikely that he knows enough about ophthalmology to make an objective judgment. His perception of the physician’s competence may, in part, have been colored by his overall opinion of the practice. But, more important, patients tend to assume that physicians who seem highly caring are also highly competent. Conversely, when physicians don’t seem to care, patients may assume that they’re not competent.

So in patient surveys, why do some physicians score particularly highly for their caring attitude? Patients like it when a doctor greets them by their name and remembers their hobbies. This reassures patients that they are getting individualized care. I know of one practice that makes it easy for its physicians to provide the personal touch: If a patient sends the practice a holiday card or is mentioned in the local paper, a staff member places a Post-it note in the patient’s chart. Patients also appreciate eye contact because this reassures them that the physician is listening. Similarly, if the physician demonstrates patience—and a good way to do that is by asking, “Do you have any more questions?”—that goes a long way toward showing a caring attitude.


What are patients saying about you and your staff?

Word-of-mouth publicity can be positive or negative, and it could make or break your practice. If you think of your patients as “referrers,” it is useful to consider them as falling into three categories:

Negative referrers. Patients who’ve had a bad experience tend to share their negative opinions with eight to 10 others. One-in-five will tell 20 people.

Casual referrers. When you meet, but don’t exceed, patients’ expectations, they will recommend you when asked but won’t go out of their way to talk about your practice.

Missionary referrers. When you exceed patients’ expectations, they refer their friends, neighbors and workmates. These patients build strong practices.


2. The staff-patient relationship. When hiring staff, remember that their attitude will have a huge impact on a patient’s first impression of your practice. If a new hire is unfriendly and unhelpful, nothing is likely to change those personality traits.

It is not enough for staff to know just enough to do their job. They should be broadly trained so they understand the full impact of what their practice is doing. (For advice on training staff, go to and see “The Five Steps of Supervision” in September and October, 2006.)


3. The office environment. Patients frequently make inferences about a practice’s medical competence based on the office environment.

  • The office should seem pleasant and clean. If the carpet seems old and the National Geographic is dated 2003, then patients may wonder, “Gee, if their waiting room is out-of-date, how up-to-date are they medically?”
  • The waiting room should be comfortable. Patients are used to having a certain amount of personal space and may feel uncomfortable if they’re forced to sit too close to strangers. So although family members may want to sit together on a couch, patients should also have the option of individual chairs. And if you select higher chairs with sturdy arms, it will be easier for your elderly patients to get up when their names are called. The temperature of the waiting room can also be an issue. Although the temperature feels okay to office staff, who are moving about, it may feel cold to patients, who are sitting still.
  • The office should look organized. If the front desk looks like a disaster, then patients may infer that the office works inefficiently.
  • Emphasize “clues to competence,” such as testimonials, diplomas and articles. If people send letters thanking you for their new eyesight, try to get their permission to put those letters on display. Similarly, physicians’ diplomas and certificates should be displayed where patients can see them.

When physicians have articles published in the professional publications or are featured in the local press, consider putting them on display.


4. Patient education materials. If you send new patients forms to fill out prior to their first visit, include a brochure about your practice.

Each exam room should include one-page handouts for the most common conditions, and you also should have brochures for any surgery that your practice frequently performs. Surprisingly, many practices seem to undervalue the importance of these materials.

In contrast to older patients, some younger patients would rather watch a DVD or use a CD-ROM than read a brochure, and this is reflected by the increasing popularity of those media.

Prior to surgery, patients should be provided with an explanation of all anticipated fees. Springing an unpleasant financial surprise on a patient is a surefire way to create a negative referrer. You also can minimize patients’ anxiety by giving them their pre- and postop instructions in writing.

Some practices are starting to send out newsletters and announcements by e-mail. If you plan to start doing this, then you should start collecting the written approval of patients to use their e-mail. And with each mass e-mail, give patients a chance to opt out.


Give Patients a Little Extra

Little things can mean a lot, provided that they are genuine.

Follow-up phone calls. This is time-consuming, but patients love it. Some practices have a member of staff program the patients’ names and phone numbers into the physicians’ cell phones, so the calls can be made during the evening commute. If the doctor doesn’t have time to make these phone calls, somebody else should do this follow-up.

Promotional gifts. I know of a refractive surgeon who has added an extra step to LASIK. After the procedure, he tells patients, “Now that we’ve taken your old glasses away . . .,” and presents them with two champagne glasses etched with the name of the practice. (Bear in mind that Medicare puts limits on promotional gifts.)

In summary, practices have four opportunities to demonstrate competence and a caring attitude. If they take advantage of those opportunities, they will find that their word-of-mouth referrals increase dramatically.


The Patient Survey

Track patient satisfaction. If you conduct regular patient-satisfaction surveys, you’ll be able to identify, and rectify, problems before they create too many negative referrers. In my experience, as soon as more than 0.5 percent of patients are negative referrers, the practice typically experiences financial problems, too.

Find out how many missionary, casual and negative referrers you have by asking, “How willing would you be to refer a patient to this office?” and providing three options: “I’ll tell everyone I can to come to this office because the care was so exceptional;” “If people ask me, I would tell them to come to this office;” and “I would tell people not to come to this office.”

Top three complaints. Based on more than 30,000 surveys, the most common complaints are:

Complaint #1: Long waiting times. I’ve found that patients tend to be quite patient with waits of up to 20 minutes, but they start to get unhappy if they’re kept in the waiting room beyond that.

Complaint #2: Brrrr . . . too cold. This complaint is particularly prevalent with elderly women.

Complaint #3: The doctor didn’t listen. Patients may assume this was the case if the doctor seemed hurried or failed to make eye contact.


Mr. Preece is president of Enhancement Dynamics Inc., a practice management consultancy. Contact him via the AAOE Consultant Directory at