Published 8/1/2011
Susan Keane Baker

Manage risk by managing patient expectations

By Susan Keane Baker

Creating reasonable expectations results in trust and confidence

Managing expectations is a process of helping patients know how to be right and when to be satisfied. Managing expectations is creating structure and process with the outcome of patient trust and confidence in you and your team.

Patients expect two types of value from their physicians: rational value and emotional value. Rational value results from appointments, examinations, surgical procedures, and follow-up visits. Emotional value is how the patient feels about having been in your care. Both your knowledge of your patient and his or her values and beliefs and your patient’s knowledge about you as a person, rather than a surgeon, contribute to emotional value.

Building knowledge in advance
One way to begin delivering emotional value is to provide information explaining what you’re about even before patients meet you. A website is an ideal vehicle for this, although other options are also available.

One of the most important parts of your website should be your philosophy of care. Your philosophy of care is the reason a patient chooses you rather than the surgeon down the street.

For example, orthopaedic surgeon Joseph E. Lellman, MD, defines his philosophy of care in this way: “I like to care for patients who understand that medicine isn’t an exact science, and that everything we do carries some amount of risk. Outcomes cannot be guaranteed, but, working collaboratively with patients, we can agree on what will constitute success. My bias is heavily weighted toward conservative treatment.”

An easy way to create the content for your website is to ask your staff members to track all the questions patients ask during a week. Then, develop the clearest, most accurate answers to these questions, and voila! you have content for your website. The “website elements checklist” can help ensure that you haven’t forgotten anything.

Once your content is posted, schedule an annual website review. A year passes quickly, and you want to keep content accurate and timely. Post the review date each time as an additional reminder.

Social media can be highly effective in communicating information to patients. Twitter is a free micro-blogging service that allows you to post information about your practice in 140 or fewer characters per posting. For example, the Cardinal Orthopaedic Institute uses social media to educate and connect with patients by introducing new physicians, providing health information, and promoting clinics. The AAOS also has a Twitter feed.

Every communication creates expectations for patients, including signs.

All too often, reception areas have multiple signs that pertain to insurance, billings, collections, and payment—but not nearly as many that help patients know what to expect or help them feel cared for. The following examples show how signs can help manage patient expectations:

  • Patients are seen in order of appointment, not arrival.
  • Kindness practiced here.
  • Please wear your seat belt when driving. We want to see you again!
  • We’re sorry we missed you. We will be open again at 9:00 a.m.

Patients who can read will read while they are waiting, which means that reception areas, examination rooms, elevators, and lavatories are good locations for posting helpful information.

Initial discussions
Savvy practitioners routinely ask patients questions such as “What did your doctor tell you about this?” or “Has anyone in your family had this procedure?” The answers to these questions will help you assess how much education and management of expectations the patient will need.

The consent discussion is an opportune time to manage expectations. Shortcutting the consent discussion by delegating the discussion to someone else or merely presenting a form for the patient to sign leaves you open to criticism if the outcome of the surgery doesn’t match the patient’s expectations. The patient who can say “Oh, my doctor told me my knee would be feverish” will be less of a problem than the one who is completely and unhappily surprised by the complication.

Identify what is important
The Agency for Healthcare Research and Quality (AHRQ) has an excellent tool that teaches patients the most important questions to ask and allows them to create their own customized list. (See the link in the online version of this article.)

Your team should regularly discuss questions that should be answered the same way, regardless of who is asked the question. This minimizes the risk that different team members will provide different answers, thus increasing patient confusion and/or anxiety.

Satisfaction survey expectations
Satisfaction survey questions help create expectations. It is in your best interest to review the surveys issued to your patients by your health system, insurance companies, or government agencies.

At your next team meeting, distribute copies of the patient satisfaction survey and have team members complete the survey as they believe most patients would. Discuss what changes would be needed to improve your scores.

When you receive your actual survey results, compare those results with your team’s predicted results to identify expectation gaps. For example, if you predicted high scores on listening to patients, but patients give you only average scores, you can develop ways to convey to patients that you do listen.

Your patient satisfaction survey verbatim responses provide information about how you are meeting patient expectations. Take time to review those comments. They will reinforce the emotional and rational value of how you care for your patients.

Just as providing a checklist for your patients is helpful in encouraging follow-through, a checklist for your practice is also a valuable prompt for enhanced performance. Consider developing a checklist to increase your own adherence to the standards created by satisfaction surveys. The Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey is an excellent resource. (See the link in the online version of this article.)

Uncover expectation gaps
Every time a patient says, “I didn’t know…” you have an opportunity to consider how to better communicate the information for future patients.

Asking for feedback is another way to identify gaps. Asking for feedback can satisfy a patient’s need to let you know that something needs improvement. The patient who is given the opportunity to tell you about his or her concerns may be less likely to vent frustration in a satisfaction survey or online chat room. Feedback questions could include the following:

  • What would make visiting us a nicer experience for you?
  • Was your visit today what you expected?

Unrealistic expectations
Often, unrealistic expectations result from a promise that wasn’t or couldn’t be kept. The following questions can be used to identify expectation gaps:

  • Have I addressed your concerns?
  • Do you know what to do next?
  • Do you know what I’m going to do next?
  • Do you know what to do if things don’t go as planned?

Acknowledge preferences
People value experiences in which their unique preferences are identified and respected. Even if you cannot honor a preference, such as a request for a morning appointment, acknowledging that preference will let patients know that you respect their individuality. The best way to respect preferences is to identify and remember them. Paper or electronic notes can be used so that everyone on the team benefits from the knowledge gained by individual members. The morning or end-of-day huddle with staff can be used for the same purpose.

Table 1: Website Elements Checklist (PDF)

Susan Keane Baker is the author of Managing Patient Expectations and a member of the Board of Examiners for the Malcolm Baldrige National Quality Award. Her website is www.susanbaker.com

Additional Information:
CAHPS Surgical Care Survey

Patient expectations: How do they matter?

Factors that impact expectations prior to total knee replacement