August 2007 | Back to Table of Contents
Clinical and Health Affairs
Professionalism among Allied Health Staff
The PLEASE CARE Program
By G. Richard Locke III, M.D., Michele Berndt, Naomi Woychick, Kathleen Gilles, Michael Schryver, and Michael Brennan, M.D.
Abstract
Professionalism affects the quality of medical care in terms of clinical outcomes, safety, and service. Although often talked about by physicians, professionalism is important for all who are engaged in clinical care. In our continuous effort to improve quality at Mayo Clinic, we hypothesized that patient satisfaction was affected by the professionalism of the allied health staff. Our aim was to improve patient satisfaction by training employees on behaviors and attitudes that could significantly affect patient satisfaction. More than 4,000 allied health staff have gone through the training program called “PLEASE CARE.” More than 2,000 patients received point-of-care surveys before and after implementation of the program. We found patient satisfaction with the allied health staff increased from 71% to 77% after the training. We also saw improvement in each of the individual PLEASE CARE attributes. This demonstrates that enhancement of professionalism among allied health staff can have a positive effect on the experience of patients.
A clinic appointment, particularly the first visit to a facility, may cause patients considerable worry and apprehension. Such feelings arise not only because of what they might learn about their health but also because they will be interacting with many new people in unfamiliar surroundings. Medical professionals have a responsibility to make sure that such concerns are not ignored or trivialized and should provide services with this in mind. Patients who feel cared for and cared about by everyone on the medical and allied health staff are more confident and trust that their needs are being met. This, in turn, can have a positive effect on health outcomes; it is also a reflection on the medical center’s commitment to professionalism.1
In 2002, the department of medicine at Mayo Clinic formed 2 work groups to consider how to improve the way clinic staff interact with patients in an outpatient setting. One group focused on interactions between physicians and patients.2 Another on those between patients and allied health staff—in particular, clinical assistants, receptionists, and secretaries. Members of the second work group, which included physicians, administrators, and supervisors of clinical assistants, endorsed the idea that patient interactions could be improved by implementing a set of service standards based on a series of professional behaviors.
To develop the standards, members of the group reviewed the results of patient satisfaction surveys, conducted literature searches regarding service standards, and solicited recommendations from clinic staff who had earned a reputation for providing excellent service within their areas.3,4 They identified and codified key behaviors that would lead to what was termed “the ideal patient visit.” This article describes the specifics and outcomes of the training program we developed, in which more than 4,000 Mayo allied health staff participated.
Methods
Focus groups were conducted with staff to identify the barriers to the ideal patient visit. Divisions within Mayo were asked to select individuals who provided outstanding service to assist with identifying the behaviors that lead to such a visit. These behaviors helped define the service standards that became the foundation for the project.
The standards identified as being critical to creating the ideal patient experience were represented by the acronym PLEASE CARE, which stands for Present, Listen, Empathize, Action, Summarize, Excite, Confidentiality, Attitude, Respect, and Emotional Intelligence. PLEASE relates to patient interactions, and CARE emphasizes the importance of putting the patient’s needs first. Because so many variables for patient satisfaction are out of allied health providers’ control, PLEASE CARE focuses on concrete actions they can take such as choosing to have a positive attitude; giving patients their immediate attention; listening; greeting and treating each person as an individual and being sensitive to his or her concerns, culture, and disabilities; and taking the time to summarize and verify complex information. Together, such actions contribute to making sure patients experience an ideal visit. Mayo retained an outside consultant to assist the team with the development of a curriculum. Together, they produced a training video. Local actors played an elderly couple arriving at the clinic for the first time and experiencing different levels of service as they ventured through multiple tests and consultations. Scenes in the video illustrated good and bad patient and peer interactions relative to the PLEASE CARE standards as well as missed opportunities to provide good service.
Employees from each division who were known for consistently providing excellent service and were comfortable presenting to a group of their peers helped facilitate the training.
PLEASE CARE training was divided into 2 sessions. The first focused on the desired behaviors and the connection between a staff member’s actions and the standard of service. The facilitators’ role was to inspire their co-workers to apply PLEASE CARE behaviors on the job and to convince them that their actions add value to the culture. Employees were encouraged to ask themselves: Where do I shine? Where can I improve? Where can I do more?
Employees also were challenged to think about the effect their actions and behaviors have on others. They left the first session with an assignment to develop a personal action plan in which they would identify specific skills they could improve on when interacting with patients and other staff members.
The second session focused on creating a culture that recognizes opportunities to continuously improve service and reinforcing the skills and behaviors that are central to PLEASE CARE. The facilitators’ role was to teach employees to recognize these behaviors and to acknowledge staff members who engage in them.
Employees were encouraged to share their action plans, and the facilitators led a discussion on whether the behaviors they outlined in those plans would make a difference in their interactions with others. Employees also were asked to identify missed opportunities and to think about which standards they valued the most and commit to adopting them.
As with any training program, the challenge is to sustain the behaviors. To maintain momentum, a group of facilitators and others developed modules and tools to reinforce the messages of PLEASE CARE. For example, poster boards on which staff could write compliments about co-workers who demonstrated the behaviors taught through PLEASE CARE were set up. In addition, physicians and supervisors were encouraged to recognize employees who exemplified the service standards.
Implementation
PLEASE CARE was piloted in 3 divisions at Mayo: 2 specialty and 1 general internal medicine. The program was then rolled out to the entire department of medicine and the department of patient support services, which employs most of the allied health staff. Four clinics outside the department of medicine also participated.
Assessment
Patient satisfaction surveys were done both before and after PLEASE CARE was implemented. The surveys were administered at the clinic and asked patients to rate the allied health staff. Questions were designed to assess whether a staff member 1) provided the patient with excellent service, 2) gave the patient his or her undivided attention, 3) listened to the patient, 4) had a good understanding of how the patient was feeling, 5) protected the patient’s need for privacy, 6) was pleasant with the patient, 7) treated the patient with respect, and 8) was sensitive to the patient’s particular needs. Other questions addressed whether problems and frustrations were satisfactorily addressed. Finally, patients were asked to rate the overall service as “excellent,” “very good,” “good,” “fair,” or “poor.”
Surveys were conducted 2 weeks before the allied health staff received PLEASE CARE training and 3 months afterwards. In the 3 pilot divisions, an additional survey was conducted 6 months after training.
The evaluations were part of the clinical quality improvement effort, thus, the staff of the Institutional Review Board of the Mayo Foundation determined that they did not require their review.
Results
The initial implementation team had 9 members who worked with 76 facilitators in the department of medicine and 40 in the department of patient support services. This group, in turn, trained 1,865 allied health staff in the department of medicine, 2,270 in the department of patient support services, and 142 in other departments. A total of 1,419 patients completed the satisfaction survey before training and 1,329 completed it after the training took place. The patients’ rating of overall care as being excellent improved by 3% (from 71% to 74%); their rating the service of the allied health staff as being excellent improved by 6% (71% to 77%). Each of the attributes of PLEASE CARE also showed improvement (Figure).
Discussion
Professionalism is important for all who are engaged in clinical care, not just physicians. We sought to improve the professional behaviors of the allied health staff working in outpatient settings in order to increase patient satisfaction by improving service delivery. Specifically, we developed service standards, then trained several thousand allied health staff on how to incorporate behaviors that meet those standards. In order for the program to be successful, the work group had to identify appropriate standards, provide effective education, have staff members practice what they learned, and make sure the behaviors had an effect on the patient experience.
We were able to show a slight improvement in overall patient satisfaction and with each of the specific attributes that were central to PLEASE CARE. The amount of overall improvement was small—just 6%; however, meaningful improvement in patient satisfaction is difficult to accomplish, and there is little data correlating customer service objectives, patient satisfaction, and quality of care in the literature.5 Because so much of what contributes to patient satisfaction is outside the individual employee’s control, we feel that small improvements in patient satisfaction are clinically meaningful. In addition, physicians are thought to influence patient satisfaction more than others, which further highlights the challenge of demonstrating the impact of a program directed toward allied health staff.
The assessment is surely not perfect. This was not a randomized trial. The results are from pre- and post-training surveys of patients, and thus any other secular trend could influence the results. Nonetheless, the patients were not aware that the training that took place. The surveys were done just 3 to 4 months apart, and thus it is unlikely that the results were confounded. Point-of-service surveys were used, which can inflate the satisfaction results compared with surveys done by mail at a later date. Still, the same methodology was used for both surveys, thus both contained the same bias.
A number of service-improvement programs exist, some of which are proprietary and most of which are not specific to health care. We chose to create our own program to meet our specific needs and incorporate features of service unique to health care.
Sustaining service standards and extending PLEASE CARE to other groups within Mayo continues to be a challenge. A core group of volunteers, facilitators, supervisors, and implementation team members meets regularly to develop additional modules. The program was added to the employee education class catalog but is not mandatory. However, all new employees in the departments of patient support services and desk operations receive this training.
Conclusion
In summary, we found that it is feasible to train a large number of allied health staff on professional behaviors and have an effect on patient satisfaction. This work highlights the importance of allied health staff professionalism in achieving the ideal patient visit. MM
G. Richard Locke and Michael Brennan are in the Program on Professionalism in the department of medicine, Michele Berndt and Naomi Woychick are supervisors in desk operations, Michael Schryver is associate administrator for clinic operations, and Kathleen Gilles is a training specialist in the department of patient support services at Mayo Clinic.
References
1. Berry LL. Bendapudi N. Clueing in customers. Harv Bus Rev. 2003;81(2):100-6.
2. Mueller PS, Barrier PA, Call TG, et al. Views of new internal medicine faculty of their preparedness and competence in physician-patient communication. BMC Med Educ. 2006;6:30.
3. Pritchett P. Service Excellence. Dallas, Pritchett & Associates, 1991.
4. Berry LL. Discovering the Soul of Service. New York: The Free Press, 1999.
5. Vukmir RB. Customer satisfaction with patient care: “Where’s the Beef?” J Hosp Mark Public Relations. 2006;17(1):79-107.