Transcript Construction of a Financial Model to Assess the Viability

Optimizing Your Practice Through
Service Values
Jonathan W. Berlin MD, MBA
ARRS 108th Annual Meeting
Business & Practice Management Seminar
April 13, 2008
Disclosure of Commercial
Interest
Neither I nor my immediate family
members have a financial relationship
with a commercial organization that
may have a direct or indirect interest
in the content of this presentation.
Presentation Overview
• Changing Landscape: Increasing Patient Consumerism,
Quality as A Prerequisite
• Quality and Service
 Differing Perceptions of Patients & Providers
• Quality Versus Loyalty
 Their differences & Importance of Loyalty
• What Does This Mean for Radiology?
Changing Healthcare Landscape
• The healthcare landscape is changing
• Gradual shift from employee based
healthcare insurance to greater individual
choice, and expense.
 Greater co-pays and deductibles
 More non-covered healthcare services.
Shift in Healthcare
• “Traditionally, employers selected health
care products for their workers and paid
for most of the services.
• Increasingly…those costs are being
passed on to individuals, who now decide
what products to buy, as well as where,
when, and how to buy them.”
http://www.mckinseyquarterly.com/article_page.aspx?
ar=1951&L2=12&L3=63&srid=17&gp=0 Accessed 3/15/07
Increased Expenses Are Driving
the Change
• “The underlying force propelling (the
movement toward increasing individual
responsibility) is medical inflation, which is
rising two to three times faster than
general inflation, so companies are
increasingly reluctant to bear the full cost
of health care.”
http://www.mckinseyquarterly.com/article_page.aspx?
ar=1951&L2=12&L3=63&srid=17&gp=0 Accessed 3/15/07
Increasing Healthcare Costs for
Corporations
• General Motors now spends about $1,525
on health care for every car it produces or roughly $6 billion in 2005.
• Ford spends more on health care than on
steel
• Starbucks spent more on health insurance
for its employees in 2005 than on raw
materials needed to brew coffee.
http://www.rightreality.com/articles/
health_care_neither_you_nor_your_company_can_afford_it.html
Accessed 4.9.07
Increased Utilization of Imaging
• On average, between 1998 and 2001,
utilization per Medicare enrollee increased
16% per year for MR imaging and 7%–
15% per year for CT, US, interventional
radiology, and nuclear medicine, while that
for radiography increased 1% per year.
• Which radiology procedures cost more?
Radiology 2005;234:824-832.
Utilization of Radiology Services
is Increasing
• Diagnostic imaging services paid under
Medicare’s physician fee schedule grew
more rapidly than any other type of
physician service between 1999-2003.
• Evaluated another way, the average
growth of physician services during this
period was 22% -- for imaging it was 45%.
http://www.medpac.gov/publications/congressional_testimony/031705_
TestimonyImaging-Hou.pdf, Accessed 12.4.07
Percent Growth in Medicare Spending Per
Beneficiary Controlled for Price, 1999-2003
45
40
35
30
25
% Increase,
1999-2003
20
15
10
5
0
Major Proc.
E& M
Minor Proc.
Tests
Imaging
http://www.medpac.gov/publications/congressional_testimony/031705_ TestimonyImaging-Hou.pdf, Accessed 12.4.07
Increasing Co-Payments and Out
of Pocket Expenses
• Increasing corporate expenditures can be
addressed by increasing out of pocket
expenses for healthcare.
• People who have to pay for their
healthcare use less and are more
discerning.
Percentage of Healthcare
Expenses in Individual Hands
• “By 2011 the fate of $550 billion to $600
billion of premiums will be in the hands of
individual decision makers, not employers
or the government.”
 McKinzie Quarterly, March 2007
Trends To Individual Spending
Producing Greater Transparency
• This is leading to trends to facilitate
decision making for healthcare consumers
• These changes include:
 a greater emphasis on healthcare quality
 transparency of health care quality &
outcomes data
 Transparency of price data
Mission of the US Dept. HHS
Value Driven Website
• Health care transparency provides
consumers with the information and the
incentive, to choose health care providers
based on value.
• Consumer choice…motivates the entire
system to provide better care for less
money.
http://www.hhs.gov/transparency/ Accessed 3/7/06
Is This Change Irreversible?
Don’t Rely on Government
• “It is highly unlikely that the health care system
will ever return to a more wholesale
environment.
• The biggest impediment is the under-funded
Medicare liability of $30 trillion—more than 2.5
times the US gross domestic product.
• This liability makes it extremely difficult for any
government to assume responsibility for rising
health care costs.”
http://www.mckinseyquarterly.com/article_
page.aspx?ar=1951&L2=12&L3=63&srid=17&gp=0 Accessed 3.15.07
Where Does Radiology Fit In?
• Radiology co-pays are increasing at the
same time that consumers are becoming
more conscious of quality and service.
• Our insurance: outpatient radiology
services only covered at 90% in 2008,
95% in 2007, and 100% in 2006
• How is radiology responding?
Imaging Economics February 2007 p. 35
Quality as Measured by
Radiologists
• Quality as Measured by Radiologists:
 Appropriate Ordering by Clinicians (ACR
appropriateness criteria)
 Protocol Selection: Type of Protocol and
Contrast Usage
Adapted from Mayo Clinic Radiology Quality Map Events and Metrics, Imaging
Economics February 2007
How Radiologists Measure
Quality
• Patient Examination: Complication Rate
• Interpretation of Exam: Accuracy,
Standardized Report, Usefulness of
Information in Report to Clinicians
• Finalization of Report: Typographical or
Textual Error Rate in Report, Timeliness of
Report Signings
Adapted from Mayo Clinic Radiology Quality Map Events and Metrics, Imaging
Economics February 2007
Adapted Mayo Clinic Quality Map
• Is Communication to Referring Physicians
Accomplished in a Timely Manner? Are
Referring Physicians Satisfied with the
level of Communication?
• Outcomes: Is the Health Outcome
Improved for Patients?
Adapted from Mayo Clinic Radiology Quality Map Events and Metrics, Imaging
Economics February 2007
The Essential Nature of Quality
• Quality Measures such as these are
ESSENTIAL for any radiology practice,
and they are admirable as well.
• Swenson: Three Reasons for Greater
Attention to Quality:
 Differentiation Among Providers
 Quality Measures Will Increasingly Be
Required by Payers
 Moral Imperative: The Physician’s Role
Quality: The Differentiator in a Flat World, Imaging Economics February 2007
Quality Measures
• Quality Measures will Increasingly
Become a Prerequisite for Radiology
Practices
• They are essential for survival and not
optional
• However…are they enough??
Lingering Questions About
Quality and Health Care
• To examine this question requires asking
some additional questions:
 Do patients and Health Care Providers have
the same means and experience to assess
quality? Do they measure the health care
experience the same way?
 Are adapting quality measures enough, or
should health care organizations also pay
attention to other factors such as patient
“experience”?
2006 Airline Quality Rating
2006 Airline Quality Rating
http://aqr.aero/aqrreports/AQR2006final.pdf Accessed 3/7/07
2006 Airline Quality Rating
•
•
•
•
Flights On – Time
Denied Boarding
Mishandled Baggage
Customers Complaints: Over sales, Fares,
Refunds, Animals, Customer Service,
False Advertising, Discrimination,
Reservations / Ticketing / Boarding
2006 Airline Quality Rating
http://aqr.aero/aqrreports/AQR2006final.pdf Accessed 3/7/07
What is Missing From This
Rating System?
Airline and Airplane Safety Data
is Absent
• Airline Safety Data
 Number and Frequency of Crashes
 Number and Frequency of Near Misses
 Number of Fatalities and Injuries from
Crashes
• Airplane Safety Data
 Age of Airplane Fleet
 Maintenance Records of the Fleet
Pilot Safety Data is Missing
• Pilot Safety Data:
 Age and Experience of Pilots
 Number of Pilots in Airline with Substance
Abuse Problems
 Exam Scores of Pilots
 Age and Type of Simulator Equipment Airline
Pilots Trained On
Reasons For Airline Data To Be
Missing
• Why is airline safety data missing?
 Because it is not really questioned by customers. As a
generalization, customers assume competency of the
airline, the pilot, and the equipment.
 Other Industries are Similar to This – Competency is
Generally Assumed
• Auto Industry: When we rent cars do we specify those with
low crash rates?
• Elevators / Escalators
• Bridges / High Rises / Balconies / Porches / Fire Safety
Patients Do Not Measure
Efficacy
• In the same manner, healthcare quality data is
not as readily accessible by customers for
clinical efficacy or outcomes.
• That doesn’t mean it’s not important – it only
means that customers notice other qualities as
well, and these other qualities impact on them,
sometimes in a more personal and up-front
manner.
Efficacy Versus Experience in
The Hospital Setting
• “Hospitals spend their efforts in clinical
results and process improvement (which)
can be measured objectively. The patient,
however, judges quality by his or her
perceptions, something that … cannot be
verified in the same way as outcomes. The
patient is judging the overall experience of
being in the hospital.”
Lee F. If Disney Ran Your Hospital, Second River Healthcare Press, 2004
Importance of Experience
• “Patients will make clinical decisions
based on non-clinical information.”
• Case of the “Dead Fish” in the waiting
room aquarium – the patient thinks, “If
they can’t take care of a fish, how can they
take care of me?”
Gabriel BA. Your Complete Guide to Patient Service,
Physician’s Practice, March 2008
Is Proven Clinical Efficacy
Enough?
Experience and Service
Increasingly Important
• “I’ll tell you what keeps me awake at night. The
quality of our clinical care is …proven and we’ve
been able to attract patients from great
geographical distances because of it. But…all
our trend data shows that consumers are
becoming more demanding and will continue to
be. It’s in our best interests to offer the service
levels and experience that patients are starting
to seek.”
• Phyllis Marino, Associate Director of Marketing, Cleveland
Clinic
http://www.interplaygroup.com/docs/Beyond_Patient_Satisfaction_
An_Interplay_Whitepaper.pdf Accessed April 2007
How are We Doing?
• How are health care organizations and
providers doing in addressing the patient
experience?
Quality and the Patient’s
Perception – The Case of Gerald
• “Too often when I speak with my son’s
doctors, we end up talking about him as if
he’s not even there. (At one) doctor
visit…his pediatrician was so clearly
pressed for time that she worked on (my
son) like she was part of a race-car pit
crew.”
Cullen T. The Wall Street Journal. 2/22/07. Putting “Care” Back in Health Care
The Subjective Nature of The
Health-Care Experience
• “It’s rare that I walk away from one my
family’s doctor appointments or dental
visits with a good feeling. It’s not that my
family is in poor health or that we’re not
receiving proper treatment. Rather, it’s
feeling that our health-care providers just
don’t have time to care about my family.”
Cullen T. The Wall Street Journal. 2/22/07. Putting “Care” Back in Health Care
Introducing Patient Loyalty
• Why is the patient experience important?
• Because it correlates to patient loyalty.
• Loyalty: A patient's likelihood to return to a
healthcare facility (Gallup)
http://www.bartleby.com/61/44/L0274400.html Accessed 4.9.07, www.gallup.com
Accessed 4.9.07
Examining Customer Loyalty
Economics
• Two companies: one with customer retention
rate of 95%; the other with retention rate of 90%
• Both companies acquire new customers at 10%
per year
• The company with 95% customer retention
increases net customers by 5% per year and
can double in size in 14 years; the company with
only 90% customer retention does not change its
customer amount in that same time.
Reichheld FF. The Loyalty Effect 1996 Harvard Business School Press
The Loyalty Effect
• 1. Loyal customers insure steady growth
• 2. Sustainable growth enables the organization
to attract and retain the best employees
• 3. Loyal employees reduce costs and improve
quality
• 4. Loyal customers insure steady volume so that
profits can be put back into the system
Reichheld FF. The Loyalty Effect 1996 Harvard Business School Press
The Importance of Loyal Patients
• Healthcare may be different than the car
business
• However, it does stand to reason that loyal
patients will seek further care, if needed,
at the same facility.
• Additionally, loyal patients have the power
to suggest referrals, increasing business.
Measuring Loyalty
• The question then
becomes:
 How do we measure
loyalty?
• Among our patients
• Among our staff
 How do we increase
loyalty?
• Among our patients
• Among our staff
Physician – Patient Relationship
Most Important Factor
• The overwhelmingly powerful determinant
of patient satisfaction and loyalty in the
group practice setting…is the interaction
between the patient and the physician.
Our studies have shown that this factor
does more to explain patient satisfaction
and loyalty than all other factors
combined.
The Satisfaction Monitor Jan/Feb 2001 Drivers of Patient Satisfaction in the Group
Practice Setting Jerry Seibert, MA, President - Parkside Associates
http://www.pressganey.com/products_services/readings_findings/satmon/article.php?article_id=186
Access 3/7/07
Increasing Patient Contact in
Radiology
• What does this mean for radiology?
• How often do we introduce ourselves to
patients? How often do we call patients with
results? How often do we go over exams with
patients?
• Have we ever had experiences with patients
where they were upset that we called them?
• Should we be increasing our patient contact?
• Could these changes foster patient loyalty?
Patient Preferences for Test
Results from Radiologists
• Over a 10 day period at University of Texas, patients in body
imaging, mamms, and ultrasound were asked the following:
 Did they want the radiologist to tell them if the results were normal
 If the results were abnormal, did they prefer to hear the results from
their primary care doctor or did they feel entitled to an immediate
explanation of their test results.
• 92% of patients wanted the radiologist to tell them if the results are
normal.
• If the results are abnormal 87% wanted the radiologist to tell them.
• CONCLUSION. Most patients prefer to hear the results of imaging
examinations from the radiologist at the time of the procedure rather
than to hear them later from the referring physician, regardless of
the findings.
Disclosure of imaging findings to patients directly by radiologists: survey of patients' preferences.
AJR Am J Roentgenol. 1995 Aug;165(2):467-9
Patients and The Internet
• According to recent surveys,
approximately 79% of patients have
internet access
• Of those, 70% would like to have access
to their medical test results on line.
• Are we as radiologists doing enough to
communicate with patients?
Gabriel BA. Your Complete Guide to Patient Service,
Physician’s Practice, March 2008
Things To Think About For
Radiology?
• Does the average patient in our
department:
 Know what a radiologist is?
 Know who is interpreting their study?
 Talked to any of the radiologists in the
department?
Prerequisites for Adequate Care
• “As with non-healthcare industries, the
number one reason for patient
dissatisfaction is lack of courtesy, respect,
and attention...
Merys RM. The Importance of Service in the Healthcare Setting: Building a Patient
Friendly Practice. Medical Group Management Association
Zagat and Wellpoint Physician
Evaluation System
• Zagat Survey and Wellpoint Health Insurance
launching free on-line consumer ranking of
doctors available to select members in its Blue
Cross and/or Blue Shield licensed subsidiaries.
• Qualities doctors will be evaluated on:




Trust
Communication
Availability
Office Environment
http://www.chicagotribune.com/features/chi-1104_zagat_d_r_nnov04,1,1307466.column Accessed 11/5/07
http://phx.corporate-ir.net/phoenix.zhtml?c=130104&p=irol-newsArticle_general&t=Regular&id=1065430&
Accessed 11/5/07
Wellpoint – Zagat Collaboration
• The four qualities of trust, availability,
communication, and office environment mirror
the Zagat restaurant guide of food, décor,
service, and cost
• The rating system is “solely designed to reflect a
consumer’s experience with a physician and not
to reflect the quality of the care they received.”
• “It gives consumers the power to make smart
decisions about selecting doctors based on
other people’s experiences.” Nina Zagat
http://www.chicagotribune.com/features/chi-1104_zagat_d_r_nnov04,1,1307466.column Accessed 11/5/07
http://phx.corporate-ir.net/phoenix.zhtml?c=130104&p=irol-newsArticle_general&t=Regular&id=1065430& Accessed 11/5/07
http://www.usatoday.com/money/industries/health/2007-10-21-wellpoint-zagat_N.htm Accessed 11/5/07
Word of Mouth Customer
Satisfaction
• “More consumers are asking for
information about what other consumers
think about their doctors to help them
make better choices.”
– Jason Gorevic, Chief Marketing Officer, Wellpoint
Insurance
• One of every nine Americans is a member
of a WellPoint health plan.
http://www.medicalnewstoday.com/articles/86306.php Accessed 11/5/07
http://phx.corporate-ir.net/phoenix.zhtml?c=130104&p=irol-newsArticle_general&t=Regular&id=1065430& Accessed 11/5/07
US Dept HHS Hospital Service
Website
• New survey website on hospitals sponsored by
the US Department of Health and Human
Services
• Government will start withholding portions of
Medicare funding if hospitals don’t participate
• “Most questions…deal with whether the hospital
always meets service expectations”
• “Survey resembles restaurant guides that rate
waiters attentiveness, dining rooms’
attractiveness and the quality of culinary
experiences.”
http://www.chicagotribune.com/news/chi-hospital-ratings_11apr11,0,3129797.story
Accessed 4.13.08
US Dept of Health and Human
Services Survey Site
• How often did nurses communicate
well with patients?
• How often did doctors treat you with
courtesy and respect?
• How often were patients' rooms and
bathrooms kept clean?
• How do patients rate the hospital?
• Would patients recommend the hospital
to friends and family?
http://www.hospitalcompare.hhs.gov/Hospital/Static/Data-Consumers.asp?dest=
NAV|Home|DataDetails|ConsumerInfo#HCAPHSMain Accessed 4.13.08
Details on HHS Website
• Website will give you percent comparison
of patient responses such as, “How often
were the hospital rooms kept clean?”
• These responses can be graphed and
compared to other hospitals.
http://www.hospitalcompare.hhs.gov/Hospital/Search/compareHospitals.asp
Accessed 4.13.08
Satisfaction Does Not Equal
Loyalty
• How do we measure patient loyalty?
• Patient satisfaction scores by themselves
are insufficient, as a satisfied customer
does NOT mean a loyal customer
• As customer expectations increase in
healthcare, scores of 1-4 on a scale of 5 in
customer satisfaction will not be sufficient.
Reasons for “5” Equating to
Loyalty
• Fred Lee: The Hotel Analogy:
• “After receiving an evaluation of a hotel I
stayed at for several days…I think back
and remember nothing special and nothing
bad…Everyone was polite, my room was
clean, everything worked. What would I
put on the survey? Probably a foursatisfied…..Loyalty is generated by
memorable things that we didn’t expect.”
Lee F. If Disney Ran Your Hospital, Second River Healthcare Press, 2004
Ways to Increase Patient
Loyalty: Basic is Not Enough
• Meeting basic and spoken requirements is
expected. Going beyond what is expected
makes the patient’s experience
memorable, differentiates physicians, and
builds patient loyalty.
http://www.pressganey.com/products_
services/readings_findings/satmon/article.php?article_id=238
Accessed 3/7/07
What Does This Data Mean
for Radiology?
Possible Suggestions for
Radiology – Patient Loyalty
• Radiologists should think about increasing
our interactions with our customers.
• This may mean:
 Introducing ourselves
 Reviewing results with patients / referring
physicians more
 Calling patients at home with discrepancies if
they don’t have primary care doctors
Six Weeks Later……
Plus a Thank You Note to the Department!!
Unexpected Outcome as
Imprinting
• To build loyalty, a failure can be a success.
• This patient certainly was not happy to
have a missed finding, but she did not
expect a personal call from the radiologist
the next morning.
• This unexpected situation made an
imprinting.
Other Ways to Build Loyalty
 Taking the time to coordinate their
radiology care if an abnormality is found
 Explaining the patient’s condition to
them
 Helping the patient take the next step in
finding a doctor
Chronic Abdominal Pain
Precontrast
Early Post-Contrast
Excretory Phase
Post-Contrast
Listening to the Patient and
Personalized Service Can
Make a Huge Difference
Two weeks of pelvic pain
What if We Don’t Have Time to
Personally See Patients?
 Consider adding physician assistants to
personally explain radiology procedures
and call patients before and after they
come to the radiology department to
answer questions
Other Means of Increasing
Service
• Web-based scheduling…
• Encouraging patients and/or families to
write down questions by providing pens
and notepads in the waiting area… and
then having someone in our office answer
them
• Think about small steps to improve patient
experiences
http://www.pressganey.com/products_services/readings_findings/satmon/article.ph
p?article_id=238 Accessed 3/7/07
Wait Times and Patient
Satisfaction
• Communicating with patients about wait
time and letting them know their time is
valuable is key to a positive office visit.
• Keeping the patient informed about wait
time may be more important than the
length of the wait itself.
http://www.galluppoll.com/content/?ci=14935 Accessed 4.3.07
Minimizing Wait Times
• More efficient scheduling & convenient
office hours
• Activities to Minimize wait –
•
•
•
•
educational DVD about procedure
Jigsaw Puzzle in waiting room
Massage chairs in waiting room
Work spaces with internet hook-up
• If long delay unavoidable, front-line
employee should apologize & re-schedule
http://jacksonorganization.com/site/english/KnowledgeNetwork/
PatientDiscoveries/TopPerformOutpatient Accessed 3.10.07
Gabriel BA. Your Complete Guide to Patient Service, Physician’s Practice, March 2008
Privacy and Patient Experience
 Privacy:
• Important both in the radiology department
and the hospital at large. Waiting rooms
where patient name was visible or said out
loud are not desirable.
 Consider other ways of identifying
patients (pagers or first names)
Patient Observations
• Billing:
 Being asked for your insurance card and
social security number every time you step in
the door is disconcerting.
 Solution: Attempt to solicit billing information
before the patient’s visit – possibly on-line
 What is covered? A point person coordinating
this would be helpful.
Building Patient Loyalty Through
Employee and Physician Loyalty
• In addition to increasing service for
patients to gain loyalty, organizations need
to build employee and physician loyalty.
Why?
Employee and Patient
Satisfaction Linked
http://radio.weblogs.com/0143030/2005/02/06.html#a47 Accessed 3/10/07
Table from Press-Ganey Satisfaction Monitor
Importance of Loyal Employees
• “You can’t achieve high patient satisfaction
when your staff is unhappy. Patients can
easily detect the dysfunctional atmosphere
bred by a team of quarreling, dissatisfied
employees.”
Gabriel BA. Your Complete Guide to Patient Service,
Physician’s Practice, March 2008
Sentiments Reflecting Employee
Loyalty (1)
• Gallup Organization has found high
agreement with the five following
sentiments correlate best with employee
loyalty:
 I have the materials and equipment to do my
job right
 At work, I have the opportunity to do what I do
best every day
www.gallup.com
Sentiments Reflecting Employee
Loyalty (2)
 The mission or purpose of my organization
makes me feel my job is important
 My associates or fellow employees are
committed to doing quality work
 This last year, I have had opportunities at
work to grow
www.gallup.com
Improving Employee Satisfaction
• What can we do to improve employee
loyalty?
 Improve communication by administration and
management
 Solicit the opinions of employees about their
work environment
 Help employees feel pride in the work they do
http://radio.weblogs.com/0143030/2005/02/06.html#a47 Accessed 3.10.07
Physician Engagement
• “The solution to (the problem of poor
physician engagement) is simple -- ask
physicians for their opinions, listen to what
they have to say, act on the information,
and tell them what actions have been
taken”.
www.gallup.com Premium Content Accessed April 2007
What Does Patient Loyalty and
Service Values Mean for
Radiology and Radiology
Practices?
Factoring Service Values Into
Our Own Radiology Practices
• How do we address the increasing need
for service?
• Factor service values into your own
practices and mission statements!
• Patient Convenience
 Ease of Scheduling
 Minimizing Wait Times / acknowledging
problems and informing patients as to why
there is a wait (if there is one)
Staff Interaction
• Staff Interaction:
 Rewarding staff for “beyond the call of duty”
service, which may include an
acknowledgement and reward for an
unsolicited thank-you note
 Point person to answer questions about the
radiology procedure
 Follow-up call after the radiology procedure to
answer questions
Patient Privacy
• Patient Discretion
 The need for patient privacy and concerns for
patient safety cannot be over-emphasized.
 Letting patients know their privacy and safety
are paramount
Billing Factors to Increase
Service
• Billing:
 Storing patient demographic information so it doesn’t
need to be repeated with each visit
 Acquiring information before the patient comes in the
door as much as possible
 Consider hiring a point person to work with patients
and answer their billing questions. This may include a
follow-up call to answer questions about forms they
may have received from their insurance carriers about
coverage.
The Role of Radiologists
• To keep up with service, the interactions
between patients and radiologists will
increase. This may encompass:
 Introducing ourselves to patients
 Meeting with patients before & after exam to
answer questions
 Having a staff member hand patients a form
with the radiologist scheduled to read their
exam if exam was performed off hours
 Follow-up calls by radiologists
Increasing Staff Loyalty
• Loyalty among physicians and non-physicians in
radiology practices should be cultivated as well.
Similar factors increase loyalty in both groups:
 Regular Meetings to discuss work environment
 Focus on identifying strengths of all group members
and attempt to foster those strengths
 Forums displaying actions based on employee
suggestions
How Do We Do It All?
• Even though the
stakes continually get
higher with quality
and service
requirements, the
needs for these
attributes only
increases.
The Future
• By focusing on patient loyalty we can
insure viability of our profession and
prevent commoditization of our product.