On sly, workers rate hospital service

The young woman slipped into a busy primary care waiting room at Beth Israel Deaconess Medical Center, took a chair in the back row, and pretended to read Shape magazine. As patients streamed in, standing in line to speak to a receptionist, she began taking notes on a form concealed in her magazine.

"She was engaged in a very long personal conversation," the woman wrote about one of the receptionists, who was talking to another employee. "At one point the line was several deep, but the person . . . was not helping to check people in."

The note-taker is a mystery shopper, one of a new breed of hospital employees in Boston and nationwide who secretly watch fellow workers to see whether patients are treated courteously and helpfully.

Beth Israel Deaconess began a mystery shopper program two years ago to monitor telephone operators who schedule appointments for patients and later expanded the program to outpatient waiting rooms in November.

Executives credit the shoppers with bringing about vast improvements, especially in telephone etiquette, with instances of poor service becoming far less frequent. Since staff began posing as patients calling to make appointments, the average customer service rating the callers gave telephone appointment specialists, on a 1-to-5 scale, jumped from 2.6 (fair) to 4.8 (excellent).

As most patients can attest, long waits, inattentive receptionists, and outdated golf magazines are fixtures of waiting room culture. But a growing number of hospitals are using mystery shoppers to gain a firsthand understanding of patients' experiences and to help gauge and improve individual staff performance.

"We're finding that as you do these kinds of programs and give feedback to staff members on the front lines, their behavior changes," said Paul Levy, the hospital's chief executive. "There's more consistency in how patients are greeted and what's done for them."

Given the number of strong medical facilities with top doctors in Boston, he said, hospitals need to compete on other fronts, as well. "If you can achieve that kind of high service quality, you don't have to market it," he said. "It spreads by word of mouth."

Beth Israel Deaconess has six mystery shoppers for 26 waiting rooms and the emergency room. They record their observations and complete a checklist with 45 items, such as whether Kleenex and hand sanitizer are available and whether televisions are set on mute. They watch whether staff members smile and make eye contact with patients, check them in for appointments in one minute or less, protect their privacy, and explain how long patients will wait.

In a January report, a mystery shopper described what happened when a man in a wheelchair asked whether his prescription was ready. The receptionist in an outpatient waiting room asked for his Social Security number, the shopper wrote, then "halfway through she interrupted him and asked him to repeat it louder," which he did. A patient on the other side of the room heard the exchange and commented, "There goes patient privacy."

In another department, a shopper noted that a staff member "was eating a doughnut at the front desk," which is not allowed.

Shoppers also found examples of outstanding customer service. During a visit to a cardiology unit, for example, a mystery shopper wrote: "One of the staff members walked over to a gentleman who was waiting and explained in a very caring manner that the physician was running late." In another instance, a shopper "was totally impressed how one assistant handled a disgruntled patient in front of everyone in a calm and apologetic way."

Supervisors review the reports with employees and reward outstanding workers with bonuses, pizza parties, and restaurant gift certificates. Those who provide inferior service get training and sometimes verbal or written warnings. "The person at the front desk sets the tone for the entire experience," said Jayne Sheehan, senior vice president for ambulatory and emergency services. "It's critical."

The secret visits seem to be working, she said. Shoppers awarded waiting room staff members an average score of 85, on a scale of 1 to 100, after a second round of visits this spring. That's an increase from 76 in January.

Mystery shopping is part of a broader trend. It is used in many different retail and service businesses.

It is also part of a broader focus on customer service at Beth Israel Deaconess. In one initiative, the hospital aims to cut the average wait for a doctor's appointment to three days. Two years ago, when the average wait was 12 days, the hospital hired more doctors, expanded clinic space and hours, and gave doctors financial incentives to see more patients. By January the average wait had been cut to seven days.

At academic medical centers, with their sought-after specialists, patients sometimes have been made to feel they are lucky to be there rather than cherished customers. "It's been more of an attitude that 'we're really busy and we'll get to you when we can,' " said Leonard Berry, a Texas A&M marketing professor who studies healthcare and other industries.

But hospitals like Beth Israel Deaconess are realizing the importance of customer service -- years after restaurants, banks, and retail stores began employing mystery shoppers -- as the market for day-surgery, medical testing, and other outpatient care grows more competitive and as government agencies and private groups start to publicly rate performance.

Berry said a growing body of research shows that good service is important in patient loyalty.

Boston Medical Center will soon start a hospitalwide mystery shopper program with callers trying to make appointments. Tufts-New England Medical Center plans to do the same for its primary care practices. Jordan Hospital in Plymouth will have supervisors inconspicuously monitor compliance with a program that requires employees to take five specific steps with patients, including introducing themselves and explaining if there is a wait.

Massachusetts General Hospital has had mystery shoppers call into its physician practices to make appointments for eight years, but it plans to end that program because it believes it has made all the improvements such information can lead to. But Mass. General is considering whether to enlist waiting room shoppers.

Brigham and Women's Hospital, however, will not mystery shop its employees. "Is it a little devious, a little misleading to staff, and how would they react?" said Dr. Michael Gustafson, vice president for clinical excellence. He also pointed out that shoppers don't capture what happens once the patient gets "behind the office door, and that's the most important part of the experience."

Instead, the Brigham plans to survey by mail 50,000 patients a year about their experiences.

Beth Israel Deaconess says it makes sure employees know they might be mystery shopped. And while the hospital surveys patients, Sheehan said mystery shopping provides immediate feedback that can be addressed quickly.

Liz Kowalczyk can be reached at kowalczyk@globe.com.