Undercover in a Hospital Bed

A nurse walked in with a loaded syringe. “Can you lift your gown?” she asked.

The woman on the gurney held the scratchy emergency room blanket closer to her chin. “What’s in the syringe?” she asked.

The nurse frowned. “Don’t you want the medicine your doctor ordered?”

The woman took a deep breath and kept asking questions. She had more than just self-interest on the line.

She was a “secret shopper,” a consultant pretending to be a patient in order to evaluate the quality and culture of care in a hospital.

Some hospitals — including the one where I work — have hired secret shoppers to pose as patients seeking care, using pseudonyms and symptoms of an illness that cannot be diagnosed or ruled out right away. They describe a psychiatric condition, perhaps, or an intermittent heart arrhythmia.

Just like any other patient, the secret shopper wears an open-backed hospital gown and a plastic identification bracelet. A nurse inserts an IV and connects telemetry leads. Next comes the usual parade of phlebotomists, doctors, X-ray techs, orderlies and more.

The secret shopper evaluates how compassionately she and other patients are treated. Do nurses wash their hands? Do doctors listen?

A trained sociologist who works with a consulting company called Etch Strategies, the secret shopper complements her observations with dozens of systematic interviews with patients, executives, nurses, doctors and beyond. When her analyses are done, she presents her findings to hospital leadership.

A few years ago, Randy Peterson, then the president and chief executive of Stormont Vail Health, a medical center in Topeka, Kan., hired Etch Strategies. Mr. Peterson, who retired this spring, said he wanted to figure out why his 586-bed hospital had only average patient satisfaction scores despite getting high marks on clinical quality metrics.

The secret shopper found clues. She observed that caregivers were sometimes brusque and even dismissive of patients. They didn’t always interact well with each other, either. More than once, the secret shopper overheard emergency room workers bad-mouthing employees from other areas of the hospital.

“They didn’t feel like a team,” she said, “and that made me doubt the quality of my care.”

Mr. Peterson said the secret shopper’s presentation of these and other analyses had his leadership team “spellbound.” A plan to make Stormont Vail Health a better place to heal quickly followed.

For example, the medical center created new tenets of employee behavior designed to improve the patient experience. Staff members were encouraged to greet people in the hallways rather than thumbing their phones while walking.

“Keep your eyes up. Socialize with patients instead of talking about patients. Tune into the social determinants of health. Everyone has a story,” Mr. Peterson said.

Secret shoppers have illuminated many aspects of the patient experience. In a 2016 study, secret shoppers contacted 743 primary care practices across California. Over 70 percent were unable to make an appointment with the original clinician they contacted, illustrating how challenging it can be to access health care. Secret shoppers have cut telephone wait times for patients of orthopedics clinics, and this spring a secret shopper study showed that more than a third of patients seeking treatment for opioid addiction were denied an appointment.

The experiences of vulnerable patients like these can be highlighted by secret shoppers. A second secret shopper from Etch Strategies presented to an emergency room in rural New York wearing sweatpants and a T-shirt with the name of an indie band. She had not showered for three days and told the desk clerk she didn’t have health insurance. This secret shopper, who in real life works in marketing and qualitative research, said it made her nervous to pretend to be someone else. But the disguise helped her make an important discovery.

“From the second I walked in, people were very short with me,” she said. “There was no eye contact. People didn’t even introduce themselves!”

At one point, a phlebotomist got the secret shopper’s blood “all over my arm and a sheet.” There was no apology. No explanation. The secret shopper said there was a stark difference between this treatment and the care she has received when fully insured and professionally attired.

Secret shoppers do expose themselves to some risk, such as blood draws, an IV, maybe even an X-ray. They decline more invasive tests and interventions, though, pleading a scheduling conflict or urgent family matter if the risks become too great.

Hospital leaders pore over reams of data. They review financial spreadsheets, patient satisfaction surveys and clinical outcome data. Secret shopper studies don’t replace that information. Rather, they attempt to give the data context.

“Stories move data from the head to the heart,” said Kristin Baird, president and chief executive of the Baird Group, a Wisconsin-based company that performs secret shopper and other consulting services for health care organizations. She has seen how patient stories that exemplify otherwise confusing trends in the data can influence health care executives powerfully.

Dr. Steve Leffler, an emergency room physician and interim president of the University of Vermont Medical Center, where I work, says he has seen secret shoppers and other work of Etch Strategies enable difficult institutional culture change by showing how clinical care feels to patients and employees.

Dr. Leffler says secret shoppers are “a mirror for all of us.” They help bring patient needs to the forefront, and they help clinicians reorient to the fundamental importance of making a human connection with every patient they see.

Tim Lahey is an infectious disease specialist and director of clinical ethics at the University of Vermont Medical Center.

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