Are your surgeons happy with your facility? What do they think about your turnover times? Equipment? Anesthesia services? Staff attitude and teamwork? Scheduling? Transcription services? What are patients telling them about their surgical experience?

To have a successful facility that surgeons want to return to again and again, you need to ask these questions, and more. To get the answers, you need a well-designed physician satisfaction survey. A survey can give you data to make solid management decisions, reveal trends and track whether they are improving or worsening, and tell you where you can get the most improvement bang for your buck.

This article will walk you through the process of designing, distributing and following up on surgeon satisfaction surveys.

1. Determine what to ask.
First, ask your staff in charge of each area (PACU, OR, and so forth) what they would like to know and what performance measurements they would find valuable. Don't ask only about your good areas-be sure to probe areas where you think you may be weak. The answers will provide a baseline from which you can launch improvement efforts.

The topics you ask about must cut right to the heart of the issues that are of importance to the surgeons. The "hot-button" issues will undoubtedly differ from facility to facility, but having been a surgeon myself, I can state unequivocally that the three major hot button issues of greatest concern to surgeons are OR turnover time, the quality of the equipment, and the performance of the staff. Here are some thoughts on how to obtain helpful data about these issues.

OR turnover time: Surgeons (and facilities) are under tremendous pressure to do as many cases they can in their allotted time; because they have been obliged in many cases to discount their services, they try to "make it up on volume." Consequently, they need the down time between cases to be as short as possible.

Different people define "turnover times" differently. One doctor may define it as the time elapsed between sewing up Patient A and making the initial incision on Patient B. Another may define it as the time Patient A is taken from the OR and the time Patient B is brought to the OR. For purposes of the survey, you need not concern yourself with defining terms. You are only trying to find out if they are satisfied with the turnover times, however they may measure them. However, if the survey yields negative satisfaction results in this area, it then becomes crucially important to establish a working definition of turnover times, so you can measure and quantify them before and after instituting a quality improvement program.

OR Equipment: You don't need to ask surgeons to provide a wish list of the specific pieces of equipment they want you to get, but you should ask how they would rate the availability of cutting edge technological equipment in your facility. Ask them to rate the responsiveness of the facility to their requests. Ask them if the equipment on hand is in good working order and if they have the other supplies they need. If quality improvement is necessary, you would then have to get into issues of quantifying how many times cases were delayed in starting, prolonged, or cancelled altogether due to equipment failure.

Staff ratings: Another key concern that surgeon have is the quality of the anesthesia providers, nurses, laboratory services, and support staff. Do the nurses have the experience to know the procedure? Do they anticipate what the surgeon will ask for and have it available quickly? Do the support staff follow instructions promptly and accurately?

This is an area in which it is vital for management to get mathematically sound data so that it is not skewed by those who are prone to being either very negative or too quick with praise.

Don't ask about areas you cannot or will not change regardless of the response. For example, if you have a parking problem and there isn't anything you can do about it, don't ask the surgeons for their opinion about parking. No one wants to be asked about something that you do not intend to change.

2. Set up the survey.
Your goal in setting up the survey should be to develop a management tool that you can use for years to come. If you set up the questionnaire incorrectly, you can seriously bias the results to the point that the survey becomes useless as a management tool. Imagine using a survey tool for four to five years, gathering all kinds of useful trending information and then learning that the tool must be changed to improve its validity. The minute you change the survey, you lose the ability to compare new scores to old ones, which is a serious loss.

I strongly recommend consulting a statistician for help with setting up the survey. For a cost of about $300 per consultation-a miniscule investment when compared to the monetary gains or losses that can result from a well designed survey versus a poor one-you will be able to ensure that you will get statistically significant results. One option you may wish to explore is recruiting someone from the mathematics department at a local university to help you with the survey.

Here are some other tips on designing the survey:

• Formulate specific, actionable questions to elicit truthful, helpful answers. You won't know what to do with a negative answer to a question like, "Are you happy with the efficiency of the center?" You will, however, know what to do about negative answers to questions like, "How would you rate the center for on-time starts? Turnover time? Ease of scheduling?"
• Use a variety of question formats to hold the participant's interest. Respondents should be able to answer most questions with a simple check.
• Break up the survey into specific areas such as Knowledge and Skill of Personnel, Equipment, Physical Plant and so forth.
• Give respondents at least five choices for each questions. Having less than five choices (for example: Excellent, Good, Fair, Poor) will skew the figures toward the positive ratings. Our survey has the aforementioned four choices plus "Very Poor." For general information questions such as "is our newsletter informative?" you can offer less than five choices, but it should still be an odd number; give an option of "somewhat," instead of just yes or no.
  
  Our facility's first survey tool provided only four response choices and biased the results toward favorable responses. It helped provide great scores, but it did not provide management with a discerning way to measure improvement or to identify areas needing attention.
  
  
• Allow respondents to remain anonymous, but require them to fill in their specialty. This will allow you to compare your ratings from one specialty to another.

3. Prequalify the recipients and send out the survey.
Send the survey to the surgeons who use your facility frequently enough to have valid opinions; you probably don't want the opinion of a surgeon who has only used your facility once or twice. Once you've sent them out, there are a number of strategies you can use to ensure that you get them back.

Be sensitive to the timing: Be aware of the surgeons' vacation time. Since many of our surgeons take vacation in July and August, we distribute the surveys in May.

Distribute a cover letter and a follow-up letter: Provide a candid cover letter from the medical director, CEO, or administrator "begging" for the surgeons' participation. Use this cover letter to explain how the data will be used and stress that their compliance is the springboard for taking steps to improve the areas where you are weak. Also, send out a reminder/thank you letter after you initially distribute the survey. This will acknowledge those who took the time to participate and may spur on the procrastinators.

Make it fun: Try to get your staff and surgeons talking about the survey. One year our staff wore physician survey badges to keep the topic in front of the doctors. Some facilities I know of even offer incentives to fill out the survey; these can be anything from dinner coupons to cash incentives.

Don't give them too long: You may think that the more time you give people to fill out the surveys, the more likely you are to get responses. Actually, the opposite is true. The more time you allot, the more likely the surveys will be set aside and forgotten. Four weeks is a reasonable time from start to finish (once the initial setup is complete).

4. Tabulate, analyze, and communicate the results.
Your first time through the results, run them by your statistician to see if you are correctly interpreting them; you may also want to use a software program to crunch the numbers and produce reports. A survey must produce statistically significant information, or you can be misled into wrongfully interpreting the results. For example, you may wonder if an 83 percent "Excellent" score one year and a 76 percent "Excellent" score the next year is a cause for concern or if it is, statistically speaking, the same score. Similarly, is an 83 percent "Excellent" one year and an 88 percent "Excellent" score the next year a great trend and worthy of staff bonuses or is it within the statistical error range of the tool and not representative of real improvement? You need to know.

After tabulating the results, send your surgeons a thank you note, and communicate the results to all levels of your staff and to the surgeons. Some facilities hold staff meetings to go through the results. We publish ours in our physician newsletter, complete with charts comparing this year's performance to past performance. We try to hit the key highlights-both positive and negative. Be certain that the physicians will be looking at the results with a critical eye-being trained in scientific methodologies, they are going to be looking to be sure your results are sound. If not, you'll hear about it!

5. Develop an improvement action plan and communicate it.
If you received statistically significant low scores in a particular area, remind yourself that's exactly why you developed to questionnaire. Figure out how to fix the problem and tell the surgeons your plan. At our facility, each department "owns" one of the questions in the survey. This helps with accountability when it comes time to take action based on the survey results. If you fail to communicate an action plan to correct a problem area, the surgeons will not bother to fill out your survey in the future, because you will have demonstrated you do not take their opinion seriously.

A few years ago our surgeons complained about deterioration in turnover performance. We created a leadership-driven process improvement team involving members of several departments. They documented that turnover times had increased to an average of 36 minutes. Because FSC is a surgical hospital doing major spine cases, bariatric surgery and total joint replacements, we had become accustomed to above-average turnover times, but 36 minutes was unacceptable. The process improvement team first sent out a letter to the surgeons stating that we were taking their complaints seriously and had formulated a team to attack the problem. They developed a plan of correction and within weeks the average turnover time had been cut to 18 minutes. A follow-up survey of the surgeons to see if they had noticed the change was much more favorable.

If you had areas requiring aggressive improvement, repeat the survey in six months to see how you're doing. If the survey results were good, an annual survey is probably sufficient and likely to produce the greatest physician participation. We feel that more than two a year, however, is probably overkill-the goal of the survey process should be to get more of an overall perspective of the facility's progress rather than the "here and now." Surgeons are typically going to be rating upon short-range recollections, anyway (which is one of the unavoidable flaws of surveying), but spacing out the timing of the surveys will provide more of a long-term view.

The process of surveying your surgeons and making adjustments based on their observations is not an easy one, but it is a vital part of your performance-monitoring efforts. What doesn't get measured doesn't get managed. There is simply no substitute for a well-designed physician satisfaction survey and a commitment to communicate the results and to do something to improve them.

Alan Pierrot, MD, is the CEO of the Fresno Surgery Center in Fresno, Calif.