Tag Archives: quality

On the question of quality context is everything

The question of quality in primary care is a vexed one. According to the King’s Fund:

We have suggested some ways that practices could begin to audit their own practice…. and made recommendations about how the work we have begun could be used as the basis for future development of quality indicators in general practice. While some of these are harder to define we think that many of these aspects of care can be captured by measuring how patients experience care. King’s Fund 2011

The issue is addressed in some detail in the report which includes the following key points:

The key activity in general practice is the consultation. The consultation has been dissected for its component parts by Deveugele et al :

8% Social behavior, 15% agreement, 4% rapport building, 10% partnership building, 11% giving directions, 28% giving information, 14% asking questions and 7% counselling.

Much of what transpires in that consultation can only be reliably interpreted within the local context of that consultation. Therefore any interpretation of the outcome must take into account factors that are not generalisable. That makes it difficult to draw reliable and safe conclusions and by corollary to set benchmarks that apply across every setting.

If the King’s Fund report makes any contribution it is that it highlights the need for further research into interventions that can be deployed within the context of the consultation to reduce diagnostic errors, to understand differences in referral rates and to explain variation in prescribing practice. It also highlights that we have inadequate data on what interventions are best deployed in the context of primary care to support health promotion.

Finally the report makes a very important observation that patients need to be more involved in their healthcare and that the patient experience should be the basis on which we focus on this issue going forward.

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Deploy rituals and be present in practice

Your next patient or client will want you to:

  • Smile (23.2%);
  • Be friendly, personable, polite, respectful (19.2%);
  • Be attentive and calm, make the patient feel like a priority (16.4%);
  • and make eye contact (13.0%).

(An Evidence-Based Perspective on Greetings in Medical Encounters- Arch Intern Med)

Showing up this way for every patient has to be a habit. Essentially you need to be “present or “mindful”. The issue of mindful practice has also been the focus of academic interest:

In 2008, the authors conducted in-depth, semistructured interviews with primary care physicians .. mindfulness skills improved the participants’ ability to be attentive and listen deeply to patients’ concerns, respond to patients more effectively, and develop adaptive reserve. Academic Medicine.

To make a habit of showing up in this way it may be worth considering deploying a ritual.

Hurdler Michelle Jenneke has her famous warm-up dance, long-jumper Fabrice Lapierre competes with a gold chain in his mouth, Usain Bolt points to the sky before breaking yet another world record, while Michael Phelps blasts Eminem to fire him up before hitting the pool. My body+soul

Consider the distinction between a habit and a ritual:

Habit

An acquired behavior pattern regularly followed until it has become almost involuntary: the habit of looking both ways before crossing the street.

Ritual

An act or series of acts regularly repeated in a set precise manner.

Rituals support habit and focus. Rituals support you to repeat habits and create new behaviour patterns over time. Daily rituals can support you to make new habits stick. You can move from doing something that might take a lot of effort, to it becoming almost automatic or done unconsciously. Mary- Ann Webb

Establishing a ritual can be the prelude to a habit.

The term ritual refers to a type of expressive, symbolic activity constructed of multiple behaviors that occur in a fixed, episodic sequence, and that tend to be repeated over time. Ritual behavior is dramatically scripted and acted out and is performed with formality, seriousness, and inner intensity. Rook, Dennis W. (1985), “The Ritual Dimension of Consumer Behavior,” Journal of Consumer Research, 12 (December), 251-264.

The pathway goes from behaviour, to ritual and then to habit. Charles Duhigg  spoke of the ‘habit loop’.This loop has three components:

  • The Cue: This is the trigger that tells your brain to go into automatic mode and which habit to use.
  • The Routine: This is the behaviour itself. This can be an emotional, mental or physical behaviour.
  • The Reward: This is the reason you’re motivated to do the behaviour and a way your brain can encode the behaviour in your neurology, if it’s a repeated behaviour.

All habitual cues fit into one of five categories: location, time, emotional state, other people, and immediately preceding action. An immediately preceding action is the most stable cue because it’s triggered by an existing habit. So to build a new habit match it with an old habitual cue.

B.J. Fogg, asks:

“What does this behaviour most naturally follow?”

To implement this technique, decide on an existing habit and complete the following sentence:

“After I [EXISTING HABIT] I will immediately [NEW HABIT]”.

Therefore to make a habit of being present for the next patient the “cue” is when you terminate the previous consultation.

The “routine” or ritual: At the end of one consult you might close the notes, tidy your desk and wash your hands. Metaphorically you also wash the previous consult out of your mind. This has physical and psychological components.

Then when you are happy that the previous consult no longer lingers in your thoughts proceed to the next consult, stand in a specific spot, call the patient, introduce yourself and smile. Shake the patient’s hand. Walk with them to the consulting room. Don’t start the consult until you make eye contact. How the patient responds to such a greeting is the “reward“.

Picture by Rob Bertholf

Doctors get to choose so much of what matters

You choose what you wear. They own the building, they chose the furniture, they employed the staff, they chose the wallpaper, they decided the policies, they set the opening hours. But whoever ‘they’ are there are only two people in the consultation. You and the patient.

You choose:

  • Your mood today
  • If you shake the patient’s hand
  • If you introduce yourself
  • Where you sit in the room
  • Where you look
  • When you stop talking
  • Whether you examine the patient
  • What you think
  • What you say and how you say it
  • What you do
  • How you terminate the consultation

And the patient chooses whether they like it.

Guess what? You get to choose so much of what matters to the patient. Choose well. You can make a difference. Create a better future for everyone.

Picture by Gilbert Rodriguez

The welcome rise of alternative providers

Two weeks ago an 80-year-old waited without food or drink for 14 hours in a Dublin city emergency department having fallen in her local supermarket. She was black and blue from head to toe a response to the call of gravity when she was launched off a faulty escalator. She was ‘triaged’ and seated next to drunken revelers who also managed to injure themselves on that fateful evening. She was seen for all of 10 minutes by a medical student and then briefly by a doctor who recorded that her visual acuity couldn’t be assessed because she didn’t have her glasses. With that, she was sent home with her granddaughter and asked to return a couple of days later when she again waited another 9 hours for a five-minute consultation presumably so that the doctor could make sure she hadn’t really injured herself and wasn’t going to sue the hospital as well as the supermarket.  I know this person and read the discharge summary even though her daughter and I live on the other side of the world. As far as we know the provider believes we should be thankful because they are very busy and at least ‘someone’ saw her.

What’s it like to be your patient?

  1. How long do your patients wait?
  2. How are they greeted on arrival and how do they feel about waiting?
  3. What do they do while they wait?
  4. How long do they see you on average?
  5. What do they expect from the visit?
  6. Why do you order tests? What difference do these tests make to the outcome?
  7. Why do you prescribe those drugs? How many people take them as prescribed?
  8. Why do you ask them to return for a review appointment?
  9. Why do your refer them to someone else?
  10. What do they tell their family about your service?

No business would survive without a handle on this information. Arguably some sectors of the business of healthcare only survive because of a monopoly.

A newer take on the organizational environment is the “Red Queen” theory, which highlights the relative nature of progress. The theory is borrowed from ecology’s Red Queen hypothesis that successful adaptation in one species is tantamount to a worsening environment for others, which must adapt in turn to cope with the new conditions. The theory’s name is inspired by the character in Lewis Carroll’s Through the Looking Glass who seems to be running but is staying on the same spot. In a 1996 paper, William Barnett describes Red Queen competition among organizations as a process of mutual learning. A company is forced by direct competition to improve its performance, in turn increasing the pressure on its rivals, thus creating a virtuous circle of learning and competition. Stanford Business

Certainly, the 80-year-old had no option but to go to a state hospital emergency department because there was a very real possibility that she had fractured something coming off that escalator. The hospital manager might say in her defense that they have no option but to offer the service as described, but where is the data to demonstrate that it is the lack of options rather than a lack of interest or talent in managing one of the most important services the state is charged by taxpayers to provide? The monopoly may be around a little longer when it comes to life-saving treatments but what about primary care? If this 80-year-old can wait 14 hours to be seen by a medical student there may be real scope for the service to be provided by someone who is qualified, will see her much sooner and offer her a cup of tea while she waits for the X-rays to be reported. What about the scope to provide better than what you offer?

Picture by Toms Baugis

No plan, no progress it’s a simple equation in healthcare

Every business manager can lay her hands on plans and policies and can probably recite the ‘vision statement’. I like the one for Lexmark printers because I think it works for healthcare clinics:

Customers for life. To earn our customers’ loyalty we must listen to them, anticipate their needs and act to create value in their eyes.

The manager’s shelves might house annual accounts, a policy for Human Resources,  a policy for health and safety, a policy for recruitment. The practice may have a chartered accountant, a registered financial advisor, a recruiter and an HR manager. Rarely if ever does a clinic have an appropriately qualified research consultant or a five year R&D plan or policy.

Therefore the manager relies on anecdotes and other people’s data to decide if the practice is delivering accessible and effective services. The practice relies on others to advocate for them and to defend the charges that are levied on their behalf. It’s all left to persons unknown in a far away bureaucracy.

The consumer relationship starts with the brand. Before you even meet the consumer, you must fully understand your brand. If you don’t know who you are as a brand, and what makes you different, better, and special, how do you expect a consumer to? You must clearly define a brand’s product benefits to set up more intimate, emotional bonds. It is these emotional bonds that will form the basis of a lasting consumer relationship. HBR

If you are a clinician in a practice what aspects of the practices’ vision are non-negotiable and how will you know if something is undermining that vision? How reliable and valid is your understanding of the following:

  1. What is the context in which the practice is located? What drives morbidity locally?
  2. How are people greeted at the practice? What do they notice about your premises?
  3. What is the commonest reason for attendance?
  4. How long is the average consultation?
  5. What is the outcome?
  6. How many people receive less than evidence based care? Why? What are the consequences?
  7. How many people take your advice? How many go elsewhere after coming to you?
  8. Which innovation is going to be introduced and tested in your practice in the next five years?
  9. What information will guide investment decisions in the practice?
  10. Are you participating in externally funded research? Why those projects and not others?

These questions are of great interest to the better companies. Companies that are ‘lovemarks’:

Lovemarks reach your heart as well as your mind, creating an intimate, emotional connection that you just can’t live without. Ever. Lovemarks

Never let innovation for a brand be something that happens randomly. It should fit strategically under the brand. At Beloved Brands, we believe the best brands build everything that touches the brand around a Big Idea, that guides the 5 magic moments to create a beloved brand, including the brand promise, brand story, innovation, purchase moment and the brand experience. beloved brands

If these issues are of interest to you I invite you to contact me to develop a plan for your practice.

Picture by UCL Mathematical and Physical Sciences

The country needs general practice to be the provider of choice

Ever since I came to Australia as a foreign graduate I have been obliged to work in a so-called ‘area of need’. Directly opposite one practice in such a location, there is a large shopping centre. I sometimes go across the road to get my lunch. I noticed several very busy outlets full to the brim with customers. Here is a price list of some of what they offer:

  1. Reflexology Foot care (20 mins) $40
  2. Deep tissue and relaxation oil massage 30 mins: $50
  3. Headache treatment (30 mins) $30
  4. Sciatica relief $45

The practice across the road is a ‘bulk billing practice’ (i.e. they do not charge more than the government subsidy). The practice feels that people ‘can’t afford to pay’. I often see the same people queueing up for the treatments mentioned above. Today ( Sunday 26th February) there is a full page add in local newspaper headed:

Hope has arrived for men over 40 with low testosterone. Now, as part of our national health drive , a limited number of Australian Men can get free assessment before 5/03/17.

A box on the page asks:

Do these symptoms sound familiar?

  • Sleep problems
  • Increased need for sleep/ feeling tired
  • Physical exhaustion /lacking vitality
  • Deceased muscular strength
  • Irritability
  • Nervousness
  • Depressive symptoms
  • Raised cholesterol
  • Erectile dysfunction
  • Lowered libido
  • Prostate symptoms

The advertisement claimed that:

Studies show that only 10% of men are receiving treatment for low testosterone.

Citing as evidence one academic paper. The other citations are to reports on a news channel. The conclusions of the academic paper are based on a survey of 2165 men attending a primary care clinic in the United States regardless of the reason for attendance. Hypogonadism was defined as follows:

Given the lack of a widely accepted single threshold value of TT to define hypogonadism, <300 ng/dl, which has been used in clinical studies of hypogonadal men, seemed a reasonable choice. (Mulligan et al)

On this basis man with testosterone, levels below 300ng/dl were classified as hypogonadal and their symptoms were attributed to that condition. The team concluded:

The difference in the occurrence of four of the six common symptoms of hypogonadism (decrease in ability to perform sexually, decrease in sexual desire or libido, physical exhaustion or lacking vitality, and decline in general feeling of well-being) was greater in hypogonadal vs. eugonadal patients (p < 0.05).

None of the men were examined for other causes of their symptoms or problems. And on the basis of this research, a clinic operating in Australia is marketing therapy that:

….stimulates natural testosterone production

There is no mention of the cost of this treatment anywhere on the advertisement. The only protection that we offer people in the face of this very questionable marketing are the services of a trained general practitioner able to help people navigate this minefield of nonsense designed to part people from their hard-earned money. However, we need to create an experience that competes effectively with the powerful commercial offerings that are triggering people to spend their money so that they are then considered ‘unable to afford to pay’ for better advice.

Picture by Angie Muldowney

General practice can evolve- it just has!

 

It’s Thursday night- I don’t blog on a Thursday night. But this isn’t any ordinary Thursday. Today I believe I walked in on the future of general practice in bricks and mortar– designed and run by a couple whose combined age is not much more than mine. I’m not quite sure what I was expecting when I made the appointment to visit. I suspect I was just being nosy- could a practice really do business without a big reception counter? I was prepared to be disappointed. To see the waiting room damaged and tired after more than a year in business. To see little more in the way of big ideas than the loss of that big ugly barrier. What I wasn’t expecting was to meet a couple whose energy and passion for general practice could easily power a small city and to leave feeling overawed by what they have created.

I saw attention to detail in everything that makes for an extraordinary patient experience. From the music in the waiting room, sounds that could be controlled from smartphones with a different selection possible in each room. Removal of the desk in the consulting room, replaced by a tablet computer fully loaded with the latest clinical software. It is a place I want to be- as a doctor, as a patient, as a visitor or in any capacity they will have me. I can’t begin to describe the impact of each room with windows designed to maximise the natural light even deep in the heart of the building, the removal of clutter (no posters anywhere), the exquisite choice of everything on display with an emphasis on less rather than more. Even the treatment room stocked in a way that makes a Toyota factory the most efficient place on earth.

I heard patients being welcomed, smiling faces everywhere, staff who said they were never happier at work. Doctors who clearly enjoyed what they were doing and a sense of purposeful calm in all that was being done.

This is what can be achieved without relying on any external agent even in a so-called area of need. It has been created by people who care enough to work very hard and want nothing less than they expect for themselves. People who want to create an experience that makes it more likely that people will value what’s on offer. Today I believe I was given a rare glimpse into what it will be like in medicine when these ideas are universally adopted because nothing less than the feelings that this place engenders is good enough.

Picture by AmadeoDM

Spend a few dollars to enhance the experience at your clinic

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Do you associate a smell with your doctor’s clinic? If you do it’s unlikely to be anything pleasant. I remember my GP’s waiting room when I was a child. He consulted, as did most doctors at that time, from his home and the patients waited in his converted garage. It was always cold and smelled-‘damp’. Not a nice place to be when you had a fever or anticipated an injection. The smell evoked the impression of being somewhere like the picture above which apparently is an abandoned hospital near Berlin. Research suggests this is not surprising:

Subjects then rated their memories as to how happy or unhappy the events recalled were at the time they occurred. Subjects in the pleasant odor condition produced a significantly greater percentage of happy memories than did subjects in the unpleasant odor condition. When subjects who did not find the odors at least moderately pleasant or unpleasant were removed from the analysis, more pronounced effects on memory were found. J of personality and social psychology

So the unpleasant memories of being ill and anticipating pain were reinforced by the musty smell of that waiting room.

We all know that smell can affect our feelings, whether it’s a loved one’s favourite perfume or the smell of a pastry in our favourite bakery. Humans are able to recall smells with an impressive 65% accuracy a year after smelling them, compared to just 50% of visuals after only three months, making it all the more important to use this additional sensory tool when trying to engage with customers. Engage Customer

Of all the things we consider about the experience we offer our patients smell is the least of them and yet potentially the most powerful. We carefully pick the colour scheme, the toys and magazines, may be even the floor coverings and the video entertainment but rarely if ever the smell. Perhaps it is because until relatively recently it was thought that humans had a poor sense of smell. However research has debunked that myth:

These results indicate that humans are not poor smellers (a condition technically called microsmats), but rather are relatively good, perhaps even excellent, smellers (macrosmats). This may come as a surprise to many people, though not to those who make their living by their noses, such as oenologists, perfumers, and food scientists. Anyone who has taken part in a wine tasting, or observed professional testing of food flavors or perfumes, knows that the human sense of smell has extraordinary capacities for discrimination. Gordon Shepherd, PLOS Biology

Here’s Engage Customer again:

Scent and sensory marketing have the potential to increase sales, boost brand loyalty, spur brand advocacy and create a strong lasting emotional connection with customers. Customer experience goes far beyond simply what meets the eye, or the ear, so try and create a lasting impression for your customers which appeals to all their senses.

Researchers shown consistently that scent has an important impact on satisfaction but also on the quality of the interactions between people in a public space. This has implications for the value of one of the ‘props’ in your practice i.e. the smell.

whats-it-aboutListen to Fred Lee  vice president at two major medical centers and a cast member at Walt Disney World in Orlando, Florida. He suggests in this TEDx talk that we should be focusing on ‘patient experience’ rather than ‘patient satisfaction’. More than 137,000 people have listened already.

We need to move away from the limitations of ‘patient satisfaction’ which is characterised by the cheesy phrase:

What else can I do for you today?

To patient experience which is all about engaging with the patient in all five senses. Some service providers are already on to this:

Airlines Infuse Planes With Smells To Calm You Down (And Make You Love Them). The Huffington post

Picture by Stefano Corso

The vital importance of seeing the patient in context

It was 2 o’clock on a winter’s morning. It sounded like the woman at the end of the phone was calling from a party. There was loud music. I barely heard what she was saying.

My three year old son has a fever, he seems to have a rash and he doesn’t like the light. He also has a sore ear. We have no way of getting to you doctor.

I couldn’t be sure what was going on so I agreed to make a house call. In those days home visits were an accepted part of UK NHS general practice. When I got to the house, 25 miles away the 3 year old greeted me at the open door. He had a mild fever and a runny nose. Mum and dad were in the lounge drinking, a neighbour was in the room and they had recently consumed a take-away meal. The air was thick with tobacco smoke. It became clear that the child had been unwell since lunchtime the previous day and after midnight when he complained more bitterly about a sore ear mum decided it was time to get the doctor. There was no paracetamol in the house.

In 2013 Mullainathan and Shafir wrote the book ‘Scarcity’. With reference to experiments in psychology they postulate that people who are labouring under some sort of lack cannot be expected to behave ‘rationally’. Not if rationally is defined as doing what professionals might consider prudent. And yet such people are perfectly rational in the sense that they behave in ways that are consistent with having to live with ‘scarcity’. This is perceived as any lack which poses an imminent threat. For the people then curled up on a sofa with wine and cigarettes the evening must have panned out in such a way that their child’s brewing respiratory tract infection had been considered secondary to whatever else was going on. I noted the sticky carpet, the wet sofa, the remains of a take away meal, the child’s filthy thread bare clothes, the baby sleeping on the couch, the dog now sniffing at my heels and the bare bulb glowing dimly over the scene while a new TV in the corner screened a quiz show.

These people could have made different decisions on so many fronts. It was obvious they had very little money but there was no reason to believe they couldn’t clean or call for help earlier. And yet looking back although it seemed that they were the authors of their own misfortune the whole scene could have been framed very differently. The young mother had been abused as a child and left home pregnant at sixteen. Her older partner was violent especially when drunk. They lived on a meagre income supplemented by social security payments. They had debts because they borrowed money (hence the new TV) and most of the income was gone even before the weekend. I couldn’t see the ‘final’ notices, the violence, the bullying employer, the menial job, the threats from money lenders, the demands from authorities- all of which reduced bandwidth in their attempts to be good parents in the small hours of that morning.

It can be frustrating when the answer to people’s problems are ‘obvious’. And yet, to those who serve them in whatever capacity they seem incapable of making the ‘right’ choice. Such frustration can be experienced most in so-called deprived areas- where the need to be proactive may be greatest and yet there is the least possibility of acting on ‘professional’ advice.

Both individual and neighbourhood deprivation increased the risk of poor general and mental health. Stafford and Marmot

The result in those communities can be a steady stream of healthcare professionals who move on having themselves experienced ‘scarcity’ in serving people with complex social problems.

A higher propensity of GP burnout was found among GPs with a high share of deprived patients on their lists compared to GPs with a low share of deprived patients. This applied in particular to patients on social benefits. This indicates that beside lower supply of GPs in deprived areas, people in these areas may also be served by GPs who are in higher risk of burnout and not performing optimally. Pedersen and Vedsted

If we are to serve people who most need creative ways to improve outcomes we have to frame their needs in the context of scarcity.  It is almost impossible to ‘motivate’ people to do the right thing when there are competing demands on their meagre resources. What is required is a new paradigm in healthcare reaffirming that those who live like this are not unintelligent or unwilling but caught in a spiral of scarcity. We need to vaccinate healthcare professionals against the danger that their skills and commitment will be eroded in such an environment. We cannot fix societal ills but better healthcare starts with recognising our response to its challenges. ‘Scarcity‘ should be required reading.

Picture by *sax

What can hairdressers teach their doctor?

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I had to try a new salon and it was an incredible experience. A long scalp massage, warm towels for my hands and an aroma-therapy treatment (3 sniffs of an oil??) made me feel ultra-pampered. I marveled at Elysa’s ability to tame my mane. The Power of a Haircut

Every shopping centre in Australia also now appears to have a massage parlour.

Stiff, painful muscles? Treatment: Myotherapy. Cost: From $100. Some companies cover myotherapy treatments under their insurance. My body+soul

Each year Australians spend over $4 billion on complementary and alternative medicine (CAM) and visit CAM practitioners almost as frequently as they do medical practitioners. But the spending doesn’t stop there:

The national survey of Australians (18-64 years)…. found over the past four weeks Australians spent an average of $594 each on clothes, accessories, beauty products and cosmetic services.Victoria, the self-proclaimed fashion capital of Australia, is home to the biggest spenders, who spend 19 per cent more than the national average at $707 a month. New South Wales spent $669 on average, 13 per cent more than average, followed by South Australia ($618) and Western Australia ($616). Suncorp bank

On the other hand a family doctor or GP might charge $50 for a standard consultation. The Medicare rebate for this is $36.30, leaving a gap of $13.70 for Australians to pay out of their own pocket. The average amount an Australian pays out-of-pocket for access to a GP is $29.56 a year (averaged across Australia).

So it seems that we are willing to pay up to $100 for one massage, $90 for one hair cut but pay a third of that sum for the services of a GP over a whole year. (Note: people pay far more for a ‘specialist’). The Value Tunnel explains this because the price is a function of the alternative options and the perceived value of that good or service. On that basis the cost of personal grooming is greater than a visit to a family doctor. It may be perceived that the alternative to visiting the doctor in your neighbourhood is to pick one who doesn’t charge above the Medicare rebate, visit a pharmacy or go to an emergency department. There are fewer viable alternatives to a haircut or massage from ‘that’ salon. There is constant downward pressure in the ‘Value Tunnel’ so that as the market accommodates more competition it drives the price down. That’s why a cup of coffee costs less than $5 and is unlikely to increase.

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What can GPs do to move up the Value Tunnel ? They must increase the perceived value while honing a niche market. While doctors no longer hold the monopoly on a range of things they also do things that others can’t offer. How can family doctors recast their brand in a way that sustains if not enhances the perceived value? Like every other business healthcare is subject to market forces. A recent survey offers businesses the following takeaways;

  • Know your customer and form a genuine relationship. What do the doctors know about their patients?
  • Make it easy for your customers to do business with you. To what extent are patients able to access what they need at the practice?
  • Solve your customer’s problems and go beyond what is expected. To what extent is the practice a one stop shop? What does the practice offer that other providers do not? ( Note: pharmacists and video consultations don’t include physical examination)
  • Look for opportunities to make an impression. Does the practice communicate well at every touchpoint?
  • Invest in your frontline staff; they are of course the face of your company, so it is essential that they happily reflect the core values you wish to promote. What are the reception staff like in the practice? Can patients be expected to be treated the same way by everyone they come across at the practice?

Picture by ndemi