Although many crossover innovations from the marketplace to the healthcare delivery sector are hailed as progress, the process sometimes generates ideas that garner much less enthusiasm and, in the case of “secret shoppers,” raise serious concerns about appropriateness.
Secret shoppers are used in retail enterprises to provide feedback on customer service. Based on this paradigm, secret shopper “patients” provide information about their experiences—scheduling, greeting, processing, waiting, and interacting with physicians—in healthcare delivery settings such as private offices, multispecialty clinics and hospitals.
Secret shoppers may be used by physicians to evaluate their own practices, by hospitals to evaluate clinics and by employers to evaluate physician employees. Commercial organizations that train and supply secret shoppers are responding to the small but growing request for this type of evaluation by advertising secret shopper patients for random evaluations. These “consumer experience” reconnaissance organizations have identified as potential clients insurance plans, patient advocacy groups, and even physician practices that want to scout their competitors’ services.
Pros and Cons
The secret shopper concept has met with support from medical facility managers
and detraction from physicians who staff the facilities. Reported benefits
from acting on patient shoppers’ feedback include better patient wait times,
increased attention to patient privacy issues, enhanced communication, and
more time for patient evaluations. Concerns have focused on the differences
between the retail enterprises where secret shopper programs originated, such
as hotels, and the more nuanced environment of healthcare delivery, where “custom
production” processes—the evaluation and management of patients—are tailored
to individual needs.
At the most basic level, secret shoppers represent an individual interpretation of experiences on an episodic basis. The information they gather, therefore, is not generalizable and cannot be converted easily into validated metrics that legitimately evaluate patient quality of care or patient safety. At best, secret shoppers serve as random auditors to assess adherence to internal or external standardized behaviors promoted by an organization, such as seeing patients promptly or respecting patients’ privacy.
Ethical Concerns
The use of secret shoppers in a medical setting also generates professional
ethical concerns. The most common scenario calls for physicians to unknowingly
enter into what they believe is a legitimate physician-patient relationship
but in reality is a secret evaluation process. Sometimes physicians are alerted
to the fact that such evaluations are being performed, but they will not know
when or which “patients” are participating in the evaluation. Other situations
make participation in patient shopper programs a condition for physician employment
or participation in a treatment panel. Because these evaluation programs cannot
be validated as true patient safety or quality of care programs, and because
they take advantage of the context of the patient-physician relationship, they
create ethical tensions for practicing physicians. The balance between a professional
obligation to participate in healthcare delivery improvement and a physician’s
right to refuse such participation, especially in the context of a physician-patient
relationship, has yet to be found.
In addition to professional ethical concerns, secret shoppers might divert resources, such as office openings for new patient appointments, from those individuals who truly need care. Furthermore, routine patient surveys and physician evaluations following office visits offer equivalent information to that provided by shopper patients but are statistically more valuable and more likely to reflect patient safety and quality of care.
A final concern about data generated by patient shopper programs, especially when generated by employers and third parties, is how that data will be used. At a minimum, the data must be stripped of information that would violate patient privacy. It seems appropriate that any data for use in physician or practice evaluation, especially when the data will be posted on a public forum, must allow for physician review, comment and, when appropriate, robust due process for contesting the validity of information gained in this manner. As use of secret shopper programs increases, such limitations could become an excessive burden to already-stressed healthcare delivery resources. Furthermore, given the weakness of the data generated by these programs compared with more robust data from instruments like patient surveys, it is advisable that physicians maintain the right to opt out of secret shopper programs.
Patrick W. McCormick, MD, FACS, MBA, associate editor of the AANS Neurosurgeon, is a partner in Neurosurgical Network Inc., Toledo, Ohio. The author reported no conflicts for disclosure.