The 5 R’s of a Successful Office Visit
David I Graber, DC, DACBSP
Years ago, I attended a session by a leading Chiropractic management consultant that shifted my perspective on patient management. He proposed that from the patient’s point of view, “You’re only as good as your last visit.” One of the keys to running a successful chiropractic practice is to master the regular patient encounter – the office visit. I have found this to be as true today as it was then.
The visit-to-visit patient experience goes beyond delivering exceptional clinical care. Over the years I have found that a successful patient office visit is composed of 5 essential elements which I have summarized as the 5 R’s: Results, Retention, Referral, Revenue, and Relationship. Here’s a brief description of each.
Results: Without results nothing else matters. Patients come to us with a need that they believe our services can satisfy or a problem we can solve. Fulfilling these makes for patient satisfaction. Unmet needs are the source of most patient dissatisfaction.
At each visit a patient needs to see and feel that something positive has happened because of the care that’s rendered. It’s not enough that our clinical indicators of improvement are met, the patient must perceive a change. They need positive feedback, otherwise all they have go on is trust and hope. That’s fine occasionally, but trust alone wears thin very quickly. It’s also an emotional strain on the doctor to continually persuade a patient that they are getting better even though they don’t notice a change.
The clinical demonstration of gain doesn’t have to be anything fancy, complicated, or high-tech. Visual cues such as posture changes, increased ROM, muscle strength, etc. will do. The feeling of less pain, greater ease of movement, less tenderness on end range joint play, or a general feeling of ease will reinforce a treatment’s benefit.
Often patients remain focused on what pain or problems they still have and overlook or ignore positive changes visit-to-visit. Pointing out what’s improved and what’s improving goes a long way toward reinforcing their recognition of the results they’re attaining.
All care rendered should be done as pleasant to the patient as possible. Minimizing a patient’s discomfort leads to more satisfaction and greater retention.
Retention: Every patient needs to have a rationale that makes sense to them to continue to seek care in your office. Patients should be reminded of their clinical goals and the plan of care to reach them.
There are 4 types of conditions in a practice, each requiring a different care plan: acute, recurrent, chronic, and wellness. Chiropractic patients frequently need a dual diagnosis for their condition, a pathoanatomical one and a functional one. The pathoanatomical diagnosis describes the state of the specific tissues causing the pain or illness. The functional diagnosis describes the abnormal function present in the patient’s locomotor, neurological, and biochemical systems that contributes to the pathoanatomical condition and their general overall health.
Acute conditions are often self-limiting, but distressful and disabling. The goal of care is to lessen the severity, shorten the duration, and promote proper healing of the episode or injury. The strategy here is treat-recover-release. The tone is upbeat and positive, “Everyone expects you to get better!” These patients are discharged to as-needed or PRN care. These patients are kept connected to the office through periodic contacts (i.e., “mailing” list & social media) and check-ins.
Recurrent conditions are acute episodes that re-occur on a regular or irregular basis. There is an underlying weakness, locomotor dysfunction, or lifestyle factors that make their condition recidivistic. These patients are best treated for the acute episode, having the relapsing factors addressed, and released on a management basis. Ideally, they are scheduled for further care in advance to intervene before the breakdown occurs.
Chronic conditions never recover. That is why they are chronic. These patients are treated more long-term to gradually relieve their signs and symptoms, and to restore and recover as much function as they can. These patients need to be regularly re-examined to assess, given feedback, and markers of progress noted to them They need home care that needs to be checked and reinforced each visit. At the point of maximum improvement, they are best put on a regular schedule of care to keep their ability to function, maintain their lifestyle, reduce symptomatic episodes, and prevent or slow their condition from worsening.
Wellness patients differ from the above in that their goals are not to treat or prevent a disease or disability, but for health or performance enhancement and feelings of well-being. These patients only have a functional diagnosis. This is the least tangible type of care to objectify a need for and is primarily driven by the patients’ subjective sense of benefit. As a result, many practitioners disregard or outright reject this form of care.
Each visit should contain some education. It’s estimated that most patients retain about 10% of what content is presented, so regular bite-sized messages are necessary. It’s a good practice to ask questions to find out what they believe and understand about their condition, their care, and the process of healing and recovery. There has to be agreement on what’s causing their problems and what needs to be done to fix it.
For care plan compliance a good practice is to make sure patients leave with their next visit scheduled, even if it’s a check-up visit months away. With online scheduling, many patients prefer the flexibility to make their own appointments. A good tracking system in the office will ensure that those patients stay on-track.
There should be an eye on the long game of future utilization. There are patients who complete their course of care and never continue or return. Mostly this is due to actions that make them feel disaffected to the office, such as: long-term care and prepayment plans, soft credit – hard collections procedures, force-feeding “philosophy” on them, aggressively soliciting for referrals, trying to convince or “close” them on care they don’t feel is needed, etc. Structure your office policies and communications to nurture a perpetual practice of patients who opt for some sort of ongoing care or to seek you again once their condition is resolved.
Referral/Review: In today’s world, most practices grow by word of mouth, a referral network, and online reviews. Practitioners in private practice cannot depend solely on good clinical care to encourage these. They must be cultivated on a regular basis, such as the office visit. This doesn’t mean blatantly asking for a referral each visit or using heavy-handed techniques like a salesperson with an upcoming quota to meet.
Developing referrals on a visit is part of an on-going marketing and communication plan that involves the entire office, not a one-off procedure. A patient’s confidence in the doctor, the effectiveness and comfortableness of the care received, a welcoming office atmosphere, and a well-run office are all intangibles that contribute to patient referrals. This “sets the table” for any referral conversation at the visit.
An overlooked first step is to make sure patients know you are accepting new patients! Pepper your office with referral messages. Next, let them know you prefer and give priority to any people they refer to you. Make sure you thank them for any referral they have made. Finally, have the right timing. Before you ask, you need to ask yourself:
“What am I doing to earn referrals? “
“Am I doing exceptional work and service, or am I merely doing my job?”
“Do they know what health or lifestyle problems I am a solution for?”
Each patient visit can provide moments to stimulate referrals through dialogue and communication. Doctors, and their staff, approach referral conversations in 3 major ways depending on their and their patient’s personalities: Direct, Inquiring, and Informing. Each has its place, but all conversations must feel natural and be done with the spirit of outreach.
The Direct approach involves an assertive call to action. It’s accomplished by telling and selling patients on the need to refer. This is a bold and sometimes brazen method for many doctors and staff.
The Inquiring approach involves engaging a patient in a dialogue with the goals of having them buy-in to the need to refer and helping them to make a referral. This is done by asking questions with an attitude of curiosity. From the generic, “How is your husband/wife/son/daughter, etc.?”, to more specifically finding out if anyone in their family or social circle have a problem that may benefit from your office’s services. “Who’s watching you?” is another good inquiring question. Many patients have others watching how they respond to care first, before actively seeking care for themselves. From their responses, the staff can artfully proceed in suggesting, guiding, or leading them to refer.
The Informing approach involves the doctor and staff giving information and education on how their care can benefit others indirectly. It also includes dropping hints and promoting referral concepts. Programs like the “case of the day” or “condition of the month” are examples of this method. Applied personally, if a patient mentions someone specifically with a problem, giving them information or general self-care tips are very low-key ways to develop a referral. Offering to speak with them, by phone, virtual or live consult, can start a relationship with the potential patient. *
Online reviews such as Google and in social media can be as effective as direct referrals. The same procedures for encouraging referrals apply for obtaining positive reviews. There are several services that will help you gather and post reviews. *
*Note: State and federal laws and professional ethical codes have restrictions on incentives or rewards given for referrals or discounting visits that need to be adhered to. Consultations, formal or informal (“curbside consultations”), or giving specific medical advice may be considered the start of a doctor-patient relationship. These encounters should be documented and followed up on as needed.
Revenue: Practices are for-profit enterprises. To generate revenue a practice’s staff needs to communicate, both verbally and non-verbally, in a way that cultivates a strong perceived value of care in the patient. On each visit review as needed the 3 Cs of sound financial patient management: Clarity, Confirmation, and Collection.
There need to be Clear and workable financial agreements made with each patient so there are no surprises. Transparency is key. These ideally should be made in writing when initially consulting the office. Confirmation of these agreements should be made as needed to keep everyone on the same page, and a new policy should be signed annually.
Collection techniques are practical, respectful, and designed to keep patient balances low or at zero. Chasing patients for outstanding balances increases stress on the office and staff. None of these are conducive a good practice experience.
Making payments to your office as simple, easy, and frictionless as possible is essential. Reasonable prepayments for a package of future services can be effective, if state and federal requirements are met. Since the pandemic, more patients are choosing digital payment methods. Make sure your office accepts credit cards, Apple & Google Pay, etc. Securely storing these allows ease of repeated payments.
Payments should be made as close to the time of service as possible. One simple and highly effective procedure to increase collections is to collect any patient payment before seeing the doctor. It is commonly known in healthcare that patient debt decreases patient satisfaction, retention, and referrals.
Doctors should spend as little time as possible discussing fees or collections with patients. This avoids having a dual role in the patient’s care and in their mind. The focus of the doctor-patient encounter needs to be on healing and service. Willingness to pay an office’s fees increases when a patient has increased value in the services provided and a strong relationship with the doctor and the office.
Relationship: The relationship between a doctor and a patient is one of the few remaining highly valued and sacred relationships left in modern society. The emotional cornerstones of a good patient relationship are Trust and Confidence in the doctor; Connection and resonance with the doctor and staff; Hope in the healing process. Clinical results may bring patient satisfaction, but relationships create patient enthusiasm and loyalty.
Fostering relationships with our patients is both the single greatest practice-building strategy and source of fulfillment a doctor can have in practice. It also provides a window into patients’ lives that will give us a better perspective on how to best serve them. Strong relationships with a patient encourage their seeking a doctor’s services in the future, rather than the “one and done” medical triage approach.
To grow a sustainable, enjoyable, and rewarding long-term practice, start by reframing the purpose of each visit. Go from solely getting optimal clinical results, to include growing and nurturing a beneficent relationship with a patient. This is a paradigm shift for many doctors, especially new graduates. Practices are built more by relationships than by clinical results. Building relationships shifts the focus from having lifetime patients under care, to having a patient for life (i.e., a relationship).
Get to know each patient a little bit better each visit. Engage in their humanity, their struggles, and learn what they need on multiple dimensions – emotional, relational, recreational, spiritual, etc. Develop rapport. Lift them emotionally and spiritually. Support their values and what is important to them. Help them reach their goals. Share in their joys and sorrows. Know when to just listen, when to comfort, and when to give them straight talk.
Your goal is to move or evolve the relationship from a transactional one (i.e., being a clinician taking care of their condition), to a transformational one (i.e., trusted advisor, coach, and confidant). When you do this you become a valuable resource and presence in their life. The steps you take to do this are small and the results are huge.
One added R is needed each visit – Recordkeeping. Good documentation meets legal compliance standards, payer requirements, and in-office needs for tracking and outcomes. It is essential for today’s modern practice to document well and do it quickly.
The foundation for practice success is built by being brilliant at basics. The office visit is one of the basics for the doctor and their entire staff to execute with excellence. The 5 R’s are a good framework for making that happen. It may not be appropriate to do all 5 on every visit, but over time try and hit all 5. It can provide benefits to the patients you serve, and to your practice.