AMA Report (3) Secret Shopper “Patients”
The subject 3 Secret Shopper "Patients" is one of a series of 8 Reports of the Council of Ethical and Judicial Affairs (CEJA) of the American Medical Association. These reports have not yet been adopted as AMA policy; they will be discussed and debated in June 2008. If they receive the support of the majority of the delegates from the state and specialty societies, they will become policy. Anyone, including the general public, can provide testimony on CEJA reports either in person at the meeting or by writing to ceja@ama-assn.org.
I am presenting each Report as a separate thread on this blog. By clicking on the link above, you can gain access to the specific wording of the Reports, 1 through 6 are to be Amendments to the Constitution and Bylaws of the American Medical Association. Reports 7 and 8 are for Informational purposes. Why should the public be interested in these reports? They are part of the ethics of the system of medicine in the United States and may be reflected elsewhere in the world. Through the practice of medicine by all physicians, the rules presented in these reports can be applied to and may affect all patients. You may write directly your comments to CEJA at the e-mail address above and, of course, you are certainly welcome to post your comments on this particular Report here.
Have you any idea what is a “Secret Shopper ‘Patient’? Actually, to demonstrate how ignorant I have been about such matters (and probably I am not the only physician to say this), I had no idea that such a “patient” could be part of my patient population until I read this Report. The Report explains:
Secret shopper “patients” are modeled on quality improvement tools developed in nonclinical service domains. The secret shopper industry has been used for decades to evaluate practices in the retail and hotel industries, primarily in the area of customer service. As of 2004 the health care industry was responsible for just 2% of all secret shopper revenue, although this represented a twofold increase over the preceding year.
They are individuals hired to act as patients to monitor service quality. The activities of a secret shopper “patient” will vary depending on what type of feedback is desired. Secret shoppers have been used to evaluate most of the steps of the patient experience, from the ease of making an appointment over the phone, to the environment and flow of patients in the waiting room, to the encounter with the physician. Secret shoppers usually record general observations and may use a checklist to record whether pre-identified service criteria are met.
There are ethical issues that are related to the use of such “patients”. The Report describes the following:
…ethical concerns can arise when secret shoppers are sent into practice settings, especially when they may interact or interfere with the care of bona fide patients or are used specifically to assess clinical skills. Some examples of ethical unease include concern that the use of secret shoppers wastes scarce health care resources, is a deceptive practice, raises privacy issues,and is not well validated as a methodology for assessing clinical performance.
Their presence in hospital emergency rooms could delay and interfere with the treatment of critically ill patients.
The Report sets forth the following recommendations:
Physicians have an ethical responsibility to engage in activities that contribute to continual improvements in patient care. One method for promoting such quality improvement is through the use of secret shopper “patients” who have been appropriately trained to provide feedback about physician performance in the clinical setting. A sound secret shopper program should include the following elements:
(1) All relevant parties, especially those to whom secret shoppers will be making unannounced visits, should be notified that this mechanism is being implemented in their practice setting.
(2) The information collected by secret shoppers should be used only to identify areas of improvement and not as a basis for punitive actions. Third parties should not have access to information collected by secret shoppers that includes personally identifying data.
(3) Feedback from secret shopper “patients” should not be relied on as the sole source of data for evaluating clinical performance.
(4) The use of secret shopper “patients” should not be implemented in a manner that adversely affects access to medical care by legitimate patients. For example, the need for urgent care (such as in the emergency department setting) must always take precedence over secret shopper “patients.”
So what do you think about a “patient” who enters a doctor’s office or clinic or hospital emergency room at the request of some party who wants information about how patients are managed there? Do you think that by following the recommendations presented, the results will be a fair compromise concerning further utilization of these “patients”? ..Maurice.
posted by Maurice Bernstein, M.D. @ 6:51:00 AM
8 comments
8 Comments:
To get an example of a nursing view regarding the "secret shopper" in the emergency room, read the brief article "'Secret Patients'": A Dangerous, Demoralizing Practice" by Gail Pisarcik Lenehan, RN, EdD, FANN in December 2004 "Journal of Emergency Nursing". She points to another article in the journal as an analogy to the risks and potential harm and waste of resources that the secret patient shopper poses:
"A medical ethicist points out, on page 559 that no one would ever consider pulling a fire alarm to evaluate the fire department staff." ..Maurice.
I don't like that precious time is wasted on an individual who doesn't need the care, when others would be better served in that time slot.
In a way it is worse if the physician is informed because they may then look at each patient, wondering if this patient is the secret patient. I think it adds a stress that can hinder the natural flow of the doctor patient relationship.
It's one thing to be a secret shopper in a retail store to evaluate customer service but entirely different to do so in a medical environment where time is of the essence, particularly in an emergent care area.
Surely the secret shopper would be someone who appreciates the dynamics of an emergency department or they could not give a fair assessment of their visit.
Doctors have enough on their plate without having to be concerned about secret shoppers.
I know that if I were warned that I might be visited by a secret shopper "patient", I would be, instinctively, on guard as I interacted with almost any new patient. And to start out with any patient with such hesitancy and unneeded concern would not be in the best interest of the patient or the doctor-patient relationship.
I feel that using secret shopper "patients" is a misguided and potentially unethical approach as a means to improve medical care. And the question still exists as to whether use of this technique has really been shown to make a significant positive impact on the way patients are treated. I think that the AMA should discourage use of such "patients" as unethical and leave secret shoppers to the marketplace. Anyway, that is my opinion. To my other visitors, what is yours? ..Maurice.
I actually think it might be useful. When patients complain about a health care encounter, they're often dismissed with reasons like "they had unrealistic expectations and didn't get what they wanted", "they wanted narcotics/inappropriate antibiotic prescriptions/some drug they saw in a commercial that they don't need and are just pissed that they didn't get it." Patients aren't treated like they're really able to assess an interaction with a doctor in a way that gives any feedback that's actually useful to the doctor. In a way, a secret shopper, who has no expectations of the encounter, who's looking to evaluate what happens objectively, and isn't ill or emotional during the encounter, might be able to give meaningful feedback to physicians about their patient interaction skills.
This subject of secret shopper "patients" is discussed with two opposing views presented in the May 2008 edition of Virtual Mentor. I would side with the second view. I think that any as yet undocumented benefit from this activity is trumped by its gross unethics! ..Maurice.
I'm not a fan in the least. ER departments are so busy these days that they don't need to be taking care of fake patients with fake ailments. The medical staff, time, equipment, etc. utilized to treat a fake patient would be much better served helping a real patient. A doctor and nurse could be dealing with fake chest pain when someone with real chest pain gets pushed back. And even if the ailment isn't as severe or potentially fatal why should any real patient have to wait longer while I fake one receives care. Terrible.
-law
As a RN on a busy hospital floor I find this tactic ridiculous. I understand wanting to increase patient satifaction, but this is counterproductive. If you put health practitioners on guard it does a diservice to the patient, and I can say most practitioners would feel on guard. Why do we have to go to these lengths; instead of things being done in secret lets have open discussions. My patients fill out satisfaction surveys everyday given by hospital management, I dont mind these at all. But to do it in secret seems like spy VS spy; it sends a message like we are not to be trusted. I can say that my job is tough, sometimes so that I wonder why I continue. But that answer comes quickly, I am there because of the patient, my duty is to them. To the think tank that thought this idea up-this may only end up hurting the trust and bond between patient and health professional. Rethink this, and to all health professionals think about it and speak out for the patients sake.
I understand the concerns related to the time that a mystery shopper could be taking from actual patients but I strongly believe that feed back to care givers is very important so that they understand how their actions and recommendations make a difference in the lives of others either positive or negative.
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