How to make patients happy

Making patients happy is not just good practice; it may even prevent lawsuits. Patients are ambassadors of goodwill for the practice. The secret to making patients happy lies in developing good communication skills. These communication skills start with an attitude of empathy and caring and letting patients know directly and indirectly that they are important. This attitude is reflected not only by what the physician says and does but also by what the office staff say and do and how psychologically comfortable the patient is made to feel in the office environment. There are a number of ways in which the office staff can show their caring.

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  Do not keep patients waiting for long periods. One of the key factors affecting patients’ overall rating of a practitioner is the time spent waiting in the reception area. Waiting time is a major cause of patient dissatisfaction, which increases dramatically when waiting time exceeds 30 minutes. Office schedules cannot always be controlled, especially if emergencies occur. For those physicians who are chronically behind schedule, the staff should take a close look at how appointments are made and try to prevent snarl-ups in the schedule. If delays are unavoidable, patients should be told why they are waiting and how long the wait may be; this helps minimize the aggravation. Also, give them options. They may wish to reschedule if an emergency has made the physician significantly late. A Service Recovery Toolkit can also be valuable. It may contain things, such as coloring books with crayons for children or a small gift certificate for a cup of coffee and dessert at a local restaurant. In addition, interesting materials should be available to help patients pass the time. These include topical and current magazines or video educational material with television sets in the waiting room ( Fig. 6.1 ). While waiting, free wi-fi access is an expected service.

  
  

  
  

  
  

  

  
  

  
  

  The waiting room should be pleasant and well decorated to make the patient comfortable.

  
  
  
  
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  Make patients feel important. The first contact the patient has with a physician’s office should be courteous, respectful, and personalized ( Fig. 6.2 ). This can include little gestures of kindness, such as the nurse asking after a recent baby, the receptionist asking for a preferred appointment time, or the physician inquiring after an ailing family member or recalling some details of an earlier conversation. In the past, it was appropriate for physicians to stand up and shake a patient’s hand when first greeting a patient and to touch patients in a neutral manner (on the arm, shoulder, or hand) during the course of a consultation. These gestures convey empathy, friendliness, and concern. Unfortunately, with the recent worldwide pandemic, these gestures are no longer a safe practice. Nevertheless, it is critical to convey information in a tone that is neither patronizing nor too technical so that the patient understands the basic problem and what is going to be done to help correct it. The physician should make eye contact with the patient being examined. Older adults often find it offensive if the physician directs advice to the younger person who may be accompanying them. Patients are often reluctant to ask questions, and it is better to err on the side of too much information rather than give insufficient information. Finally, physicians should not make patients feel they are too busy to listen to their problems, because patients may not only go elsewhere but also be thoroughly dissatisfied and litigious.

  
  

  
  

  
  

  

  
  

  
  

  An ophthalmic assistant should be warm and courteous and make the patient feel at ease.

  
  
  
  
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  Create space for comfort. Surprisingly small details, such as how the furniture is arranged, can make a difference in overall patient response. In an eye practice, a desk intervening between a patient and the ophthalmologist often serves as a barrier to communication. It is much better to have a direct, closer interaction with the patient. Both intimacy and empathy are given a head start by placing the chairs near each other to eliminate any broad expanse of space between physician and patient.

  
  
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  Respect a patient’s right to privacy. Any discussions of fees with the physician or receptionist should be conducted privately so that details of these conversations are not overheard by a room full of strangers. Confidentiality is important.

  
  
• 5.
  

  Look the part. Some patients do not respond well to individuals with long hair or those dressed in blue jeans, sports shirts, athletic shoes, and sports socks. To earn patient respect, the physician and staff members should wear conservative business attire or the practice uniform. A consistency in color among the staff or laboratory coats may serve the purpose of professionalism. Nametags of the staff are a friendly gesture.

  
  
• 6.
  

  In the examining room, pay attention to detail. Unclean examining rooms make patients uneasy, especially when evidence from previous examinations is clearly visible. Cleanliness is an important image for patients, so provide hand sterilizers, for example, Fig. 6.3 . Interruptions during an examination can be particularly annoying. A loud intercom system undermines privacy and is unprofessional except for emergencies. Small conveniences, such as a coat rack in the waiting room, along with soothing decor, plants, and art prints, all help to create the impression of a pleasant, welcoming environment and a caring physician. Redecorating every so often may be a good plan. Old or worn-looking magazines is a definite no. Putting magazines into clear plastic holders will keep them looking fresh.

  
  

  
  

  
  

  

  
  

  
  

  A hand sanitizer for staff and patients is useful to show that the office cares.

  
  
  
  
• 7.
  

  Master communication skills. Conversation is an important factor in making or breaking the physician–patient relationship. Here are a few tips:

  
  
  
  
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    Be upfront. Give information right at the beginning of the visit and not at the end. One can talk while examining with a slit lamp, retinoscope, and so on. Friendly conversation is appreciated

    
    
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    Be creative. Use everyday language to explain what is wrong and how you are planning to correct it

    
    
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    Be personal. Ask questions about patients’ families, social life, and work situations so that they feel they have not been forgotten from one visit to the next. Make notes on charts about patients’ interests and concerns for recall at future visits

    
    
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    Be prepared. If you have something that needs to be shared with a patient’s family, ask them to come in from the waiting room and share the information with them

    
    
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    Solicit patient feedback. Confirm that what you have told the patient has been understood by asking the patient to relay the information back to you. This is particularly important for educating patients about care systems for contact lenses. Too often patients leave the office unable to manage their contact lens care systems. Written information will ensure that the message gets across. Handouts are very important and are even more effective if they are personalized. Keep the materials fresh. Update often and do not make copies of copies that end up looking unprofessional and show a lack of attention to detail.

    
    
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    Be human. Patients want human beings looking after them. It is perfectly acceptable to tell patients that you also feel bad when the news you have for them is bad.

  
  
  
  
• 8.
  

  Be fair in all matters of finance. Charge fairly for your professional services but do not overcharge. Be fair in providing refunds to patients who prove to be unsuited for contact lens wear. Always look at the situation from the standpoint of the patient. Maintain goodwill at all costs. It is a truism that one happy patient will let one other person know of your great service but one unhappy patient will tell ten about their bad experience.

  
  
• 9.
  

  Never ever put anything on the records that would be damaging if the records appeared in a court room, for example, the patient is crazy.

Scheduling appointments

It is difficult in an ophthalmology office to be on time. Because many patients require dilating eyedrops, it means everyone must wait at least 30 minutes. Therefore waiting patients are always present. If emergencies or difficult cases are added, then the normal waiting time can be extended to 1 hour. Waiting is tedious. No one likes to sit beside a total stranger for prolonged periods. Patients become irritated and their tempers grow short. The irritability spreads and affects the entire staff. A hostile patient does not foster good doctor–patient relations.

If waiting is a fact of the office environment, the best way to prevent a potentially disruptive situation is to explain on the patient’s arrival that a wait of 30 to 45 minutes may be required to allow for eyedrops and a preliminary examination before the patient sees the ophthalmologist. It does not change the reality of waiting but at least the person knows what to expect and, more important, the reason for the delay. If it is a reasonable explanation, most patients will understand and accept the distress of sitting around. Occasionally, a patient will be unreasonable and short-tempered but one cannot satisfy everybody. The assistant should always forewarn patients about the necessity of waiting for the doctor and explain why. Available coffee, tea, or soft drinks along with a TV monitor help goodwill. For those waiting, free wi-fi access is a must.

The waiting game can produce bitterness on both sides. For the physician, the patient who does not show up for an appointment, or shows up late, has kept the clinician waiting. Some physicians charge for missed appointments. A valid case can be made for doing so, because time is the major commodity for the professional. Many patients feel the same way. Who is to say that a physician’s time is more important than anyone else’s? Some patients have billed their physicians for lost time spent uselessly in a waiting room. Of course, these views represent the extremes of the doctor–patient dispute.

It is difficult to control the size of an eye practice and simultaneously retain patient goodwill. A well-trained ophthalmic assistant can be the solution, in whole or in part, to the doctor’s dilemma. The ophthalmic assistant responsible for telephone appointments acts in the role of doorman to the practice. The assistant is, after all, the first contact the patient has with the office. He or she can attract or discourage new patients or drive away old ones.

The ophthalmic assistant may not be primarily responsible for the scheduling of appointments but should act in a supervisory capacity to see that the physician’s appointment schedule is not overcrowded. Any appointment system must be formulated to suit the particular working habits and peculiarities of the physician involved. Appointments must be generously spaced and an adequate amount of time allocated for any special procedures that are to be performed. An efficient appointment system makes allowance for the fact that many patients will require eyedrops. Special consultations for problem cases will require additional time apportioned to the patient’s visit. Emergencies often arise during the course of the day and blocks of time may be set aside to permit the efficient, smooth handling of these emergencies with minimal disruption of the existing schedule. A routine daily huddle with the physician and assistants allows schedules to be refined. Knowing what worked, or did not work, yesterday allows scheduling mistakes to be minimized and leads to a continual improvement of the schedule. We can learn from our mistakes and successes.

No one should rely on memory in recording an appointment. All appointments must be marked in the appointment book, preferably in pencil so that they can be erased in case of cancellation. A more efficient way to handle appointments is a computerized scheduling system. This allows instant recall if someone calls in about a future appointment. This is now the most common way, but it depends on a staff person who is computer literate.

In making an appointment, it is important to spell the name of the patient correctly. The telephone numbers, both home and business, should be obtained in case it is necessary to contact the patient to alter the time of the appointment. The appointment time should be repeated to the patient at least once, so that there is no misunderstanding about the date and time. Whenever possible, patients should be given the first available appointment time suitable for their needs. Tactful questioning of the patient should reveal who referred the patient, whether it was a physician, an optical house, an optometrist, or another patient. It is a matter of good public relations to note this person in the appointment book, as a reminder when the patient arrives.

More time should be allowed for first visits because the doctor will require and usually will wish to spend more time examining new patients. When special tests or procedures are anticipated, such as visual fields or minor surgery, they should be noted and suitable time permitted. The appointment schedule should be marked in advance whenever the physician is attending meetings or conferences so that double bookings do not occur, to avoid cancellations and rescheduling.

It is false economy to book patient appointments too close together and not leave adequate time for individual staff, department, and all-staff meetings, or to fail to put major policies and group decisions in writing. Hallmarks of the most successful practices include:

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  Doctor breakfast or lunch meetings to communicate as colleagues

  
  
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  Roundtable sessions to solve specific problems at a set time

  
  
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  General staff meetings

  
  
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  Suggestion boxes strategically placed

  
  
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  An annual retreat

  
  
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  A written procedure and policy manual

  
  
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  Weekly staff bulletins

  
  
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  Email communication to staff

  
  
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  Routine physician/staff huddles

Booking the arriving patient

When a patient arrives at the office, certain documentation procedures must be performed to obtain the vital information necessary for the complete charting of the patient. The area of introduction of the patient to the staff should be pleasant. Records should be readily available.

If the receptionist has a good memory, greeting the patient by name on arrival is good public relations. If not, tact in obtaining vital information is important. Many patients will be reticent about giving their age, particularly in front of other patients. Insurance numbers and statistics on financial affairs must be tactfully handled. If a verbal request for information does not provide sufficient confidentiality, a blank information card on a clipboard can be given to patients to complete while they are seated and then returned to the receptionist. This is preferable to asking for confidential information in front of others. Ensure Health Insurance Portability and Accountability Act (HIPAA) confidentiality requirements are maintained. Always use two identifiers to ensure that you are speaking with the patient whose chart you are reviewing.

All patients should be given a warm welcome, just as if they were being received into a home. They should feel wanted and comfortable no matter how busy the office situation at the time. Each person should be treated as an individual. Some personal detail that may have been noted previously should be inquired after if the receptionist knows the patient.

Records of patients seen previously will be obtained from the files. If the patient has never been seen before, a new record is opened and all the vital information recorded. This process should be part of a written policies and procedures manual.

Once the day begins with the scheduled appointments, it is important that there be minimal delay in the processing of each patient. Before the patient is seen by the ophthalmologist, politeness, kind words, and a cheerful “hello” will go a long way in promoting goodwill for the ophthalmologist and the office. The office assistant should always speak to the patients and assure them that they will be seen shortly by the doctor.

In ophthalmology, because eyedrops are usually instilled and the patient must wait a given length of time, a proper flow of patients into different rooms should be planned. The placing of patients into designated rooms by the ophthalmic assistant will ensure proper attention by the ophthalmologist with minimal delay. Patients with sore or painful eyes should be seated in the waiting room in such a position as to avoid facing glaring lights.

The reception room

Once in the office, the patient should not have to wait more than 15 minutes before being shown into an examination room. Those 15 minutes in the reception room should be comfortable and pleasant.

A wide variety of current reading material will occupy patients as they wait. Chairs should be spaced so that each patient has elbow room and does not feel cramped up to another person. As a courtesy to patients who find cigarette smoke irritating, you might post a sign that reads “Smoking not permitted in this healthcare facility.”

Many offices have educational brochures available that explain common eye ailments. The reception room is a perfect place to circulate patient information brochures or past newsletters and to dispense information about the practice. Brochures might contain information on office hours, insurance, emergencies, and new medical developments for eye conditions. Ensure these are updated regularly.

The decor of the reception room should create a bright, cheerful atmosphere. Artwork, photographs, plants, and fresh-cut flowers will assist. Depending on the doctor’s wishes, the assistant may choose to have coffee, juice, or water available to patients on request. A TV monitor with low or no sound may be of help.

Avoid personal conversations with other staff members or on the phone with friends because these often can be overheard by patients. It is not always apparent when a patient is just around the corner. Staff must be professional at all times.

Running late

No matter how carefully an appointment system is planned, delays and waiting periods will occur in a busy ophthalmic practice. Unlike other specialists, who can control to a certain extent the number of return visits, ophthalmologists, because of the number of emergencies encountered coupled with demands from referring physicians, have difficulty in adhering to a fixed schedule. Ironically, the qualities that make them run late are the qualities that make them available to patients. When an emergency patient calls, an ophthalmologist says, “Yes, come in and I will take care of you.” When a patient talks about ailments (or problems that may be causing the illness), a good doctor will not shove the patient out the door just to stick to a schedule. When confronted with a complicated eye problem requiring extensive testing, a competent ophthalmologist, no matter how busy, will take the time to arrive at the diagnosis that sometimes may be not only sight saving but also lifesaving.

When the doctor is running late, if the waiting patients begin complaining, the ophthalmic assistant should give them a little insight into these facts.

Scribes

Scribes are a major time saver for an ophthalmologist in the recording of information. They can increase the productivity of the office and reduce patient waiting time.

Some ophthalmic assistants train to be a scribe for the examining ophthalmologist. They must be familiar with ophthalmic vocabulary, as well as vocabulary shortcuts, symbols, and testing equipment. They should have legible handwriting or excellent typing skills. Ophthalmic scribes can save time in an office not only by recording the examination details but also by prewriting prescriptions for drugs and spectacles for the licensed doctor’s signature. They also assist when reemphasizing instructions while the doctor sees the next patient. Ophthalmic assistants’ knowledge will increase by virtue of the fact they will eventually see and hear about every ophthalmic disease, disorder, and treatment.

Another advantage of a scribe to an eye practice is that it allows the physician more face-to-face time with the patient. Forms are often delegated to the scribe to fill in then return to patients immediately, rather than by mail.

The ophthalmologist should verify that clinical notes and forms are completed accurately.

Scribes’ signatures should be placed for medical-legal purposes, and on electronic records, scribes should have their own password.

Making future appointments

If a repeat appointment is required within the next 2 to 3 weeks because of iritis, conjunctivitis, glaucoma, or postoperative care, this appointment should be made at a designated time that does not overcrowd an already crowded appointment schedule. Usually these repeat visits are short so they can be scheduled before other regular appointments or integrated into the appointment system by a reserved block of time at the end of the appointment system.

It is also important for working patients that repeat appointment times be given early in the day. A minimal amount of delay is expected in the appointment system at that time because unexpected emergencies tend to occur as the day progresses.

Financing

There are a number of financing companies that provide excellent resources to finance expensive procedures for the uninsured or underinsured surgical patient. These companies also provide handouts, newsletters, emails, and support staff to inform patients of the availability of financing for surgery.

Recall cards

Recall cards probably are the single most important vehicle an office has to maintain a regular, steady flow of patients. Many patients need to see an ophthalmologist only every 3, 6, or 12 months. Keeping a record of when they are due for their next examination is a method of ensuring that they receive continuing eye care, particularly for glaucoma or postoperative patients. It is difficult to provide the quality of eye care necessary if people forget or neglect to check their eyes. A recall card is a friendly reminder inviting them to call the office to schedule an appointment at their earliest convenience.

If your EMR does not provide for an automated recall system, the best way to establish a recall card system is to set up a tickler file and keep it near the last person to speak with the patients before they depart from the office. At that time, the physician’s notes can be read and a recall postcard addressed with the month of suggested return on it. It is then filed in the tickler file according to month. At the beginning of each month, the recall cards that are in the file for the following month should be sent out. Some offices like to follow up the recall card with a personal telephone call. Future appointments may be made as far ahead as 1 to 2 years in an appointment book or computer. It is important to remind these patients by SMS (text), email, postal card or by telephone at least 1 to 2 weeks and also 1 to 2 days before the appointment. Rescheduling may be required if the date selected is no longer convenient for the patient.

Automated voice machines

There are several companies offering telephone assistance for offices to optimize patient communication. We are familiar with the TeleVox system, which provides caller ID on all incoming calls, prompts the caller to transfer to specific departments—such as to schedule appointments—and provides extensions to speak to live personnel. The system messages can be customized and changed to suit the priorities of the office.

The system can also be used for appointment reminders for scheduled patients, at an appropriate time 2 to 3 days ahead of their appointment. This can be achieved by simply entering the database of upcoming patients and can essentially reduce the “no show” rate by 35%. This also provides an opportunity to fill the appointment holes with transfers, emergencies, referrals, and so on, and helps raise the overall efficiency of the office.

The recall message can be produced in several languages, a nice touch for some, which may help to reach out to patients who have never returned.

Filing

Filing is an important aspect of everyone’s everyday practice. If a file is lost or misfiled, a great deal of valuable information may be lost, including measurements that may be impossible to obtain again. The doctor may have to spend considerable time trying to recover information. Anyone may remove files from the filing system, but only one person should be delegated the responsibility of refiling. When a file is misplaced, everyone may be called on to aid in the search for the file. Often the file may have been removed for reports, letters, surgery, and so on.

Most ophthalmic offices have a central filing system, with files placed in alphabetic order. These systems may be further subdivided by an active drawer, which includes files of patients who are under active treatment and who will be returning within the next 4 weeks. Some hospitals and offices file their charts under a numeric system. This is more efficient and minimizes lost files, but it requires additional work. Each chart is numbered in order of being opened and it is filed accordingly. Cross-references are made of all names, in alphabetic order, and even double cross-referenced so that any special foster names or married names are indexed. In an alphabetic system of filing, the controversial order of names, such as those beginning with Mac and Mc and names such as DeForest are filed according to an agreed-on procedure, which must be known to all. In addition, common names, such as Brown, Smith, and Lee should be arranged in the order of the initial of the patient’s first name. The numeric filing system eliminates these challenges and minimizes the number of misfiled records.

It has been our practice to separate the financial from the clinical records for each patient seen. With the advent of Medicare, we have found it expedient to change our patient processing routine so that the financial records, including billing and posting, are prepared at the time of the patient’s office visit. The first statement and an account for submission to the insurance company can be given to the patient at this time.

Laboratory and x-ray reports, along with letters from other physicians, must be appended to the patient’s chart and brought to the attention of the eye doctor. It is unacceptable to simply file such letters with the chart until the next patient visit without them being seen by the eye doctor.

Missed appointments and cancellations should be noted on the patient’s chart and brought to the doctor’s attention. Sometimes important litigation hinges on this type of information.

Files should be purged at least annually to allow more space. Outside storage is an option if space is limited. Files of known deceased patients and very old files should be purged regularly and sent to a shredding service or shredded onsite if available. One should establish a year date for the last visit (e.g., 7 years, 10 years) before deleting a file. The practitioner’s office should have a policy for length of retention of medical records that follows state or provincial laws and advice of the practice’s malpractice insurance company.

Electronic medical and health records

EMRs and electronic health records (EHRs) are a computerized medical records system created in organizations that deliver health care, such as hospitals, integrated delivery networks, clinics, ambulatory surgical centers, and healthcare provider offices. These records make up a healthcare information system that allows for storage, retrieval, and modification of the healthcare record.

The terms EMRs and EHRs are often used interchangeably, although technically EMRs represent a duplicate of a paper-based charting, whereas EHRs are electronic records with the ability for electronic exchange of patient data from practice setting to practice setting. These electronic records can contain a wide range of patient data including patient demographics, medical history, medications, allergies, immunizations, vital signs, physical examination findings, laboratory tests, radiologic images, photos, prescriptions, and billing and insurance information.

EHRs are being heavily promoted by federal and state governments, insurance companies, and large medical institutions as a system to help physicians and office staff better care for patients before, during, and after healthcare encounters. Because of these promotions, EHRs are being incorporated into the vast majority of healthcare provider offices. They are ways to improve efficiency, promote quality improvement, overcome poor penmanship that contributes to medical errors, and offer standardization of forms, terminology, and abbreviations. They allow for data input for collection of epidemiology and clinical data. Barriers to adoption of electronic records include start-up costs, system maintenance costs, and training costs. Patient privacy issues are of concern with electronic records because of their portability and potential access by unscrupulous users and unauthorized individuals. It is necessary that all HIPAA requirements be met.

Prescription pads

Each prescription for a medication should be signed by the prescribing doctor. For most of those with EMRs, the prescriptions should be created in the application and sent electronically to the patient’s pharmacy of choice. Blank prescription pads should be kept in a drawer so a patient (or staff member) is not tempted to steal a pad and self-prescribe a narcotic or other medication.

Office equipment

Equipment is an important factor in office efficiency. The ophthalmologist or office manager must constantly be on the watch for new business machines that may improve office efficiency. These include calculators, postage meters, and multifunctional devices, which normally include the copier, scanner, e-mail, and fax functions. One also must watch for new ideas in billing procedures and form procedures that will be helpful. Floor and wall coverings that reduce noise should be used. Seats should be arranged to relieve back strain. Stamping and sealing envelopes by machine greatly facilitate the speed of these procedures. The telephone system should be regularly reviewed to ensure that one has the most efficient system available and that proper lines of communication are established between rooms, through either the telephone or an intercom system.

The personal computer, which is now standard in the ophthalmic office, is discussed in detail in Chapter 20 .

Ophthalmic equipment is very precise and must be kept in perfect working order. Basic principles to consider include the following:

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  Keep the machines (slit lamp, keratometer) covered when not in use.

  
  
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  Regularly check the accuracy of such devices as the radioscope, keratometer, and lensometer.

  
  
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  Learn to maintain the instruments, from changing a bulb in the projector to attaching a topogometer.

  
  
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  Make sure regular maintenance is performed for such instruments as the automatic refractor, keratometer, pneumotonometer, visual field, and corneal topography machines.

Personal qualities for improved office efficiency

Avoiding interruptions

Before leaving the office at night, create a to-do list for the next day and prioritize the order. Organize a special me or personal hour (preferably early in the morning) and turn all phones and distractions off. Tell your coworkers you want “peace and quiet” to do a special project. You will probably complete this in half the time! Do not become distracted by other tasks or emails on your computer; if you have a door, close it. If you work in a cubicle, put up a “do not disturb” sign, and if appropriate devote at least 1 to 2 hours a day to uninterrupted work. Tell other assistants what you are doing and they will probably do the same.

The attitudes of each of us are based on our likes and dislikes and are expressed in our words, our actions, and our behavior. Some of these attitudes become habits, some of which are helpful and some harmful to ourselves, the people we work with, and the patients we greet. The ophthalmic assistant should analyze these attitudes and try to eliminate those that are inappropriate.

An attractive personality depends on an expression of physical, mental, social, and moral qualities. Physical qualities give first impressions to people we meet. Our appearance, voice, manner, energy, and bearing portray a first impression to the patient. Social qualities are developed through our everyday contacts with people. To make a favorable impression one must be considerate of others, cooperative, and courteous and show tact, cheerfulness, and kindness. In addition, patience and sympathy must be part of one’s personality. These attributes create a pleasant and stimulating atmosphere in the office.

Mental qualities include intelligence, a keen observation, a retentive memory, and an ability to concentrate and apply oneself. The ophthalmic assistant must be orderly, accurate, and careful in conduct, show an ability to intelligently and quickly answer the many questions that patients ask, and above all show a good sense of humor.

Moral qualities, the foundations of character underlying everything else, include honesty, sincerity, loyalty, and trustworthiness. The ophthalmic assistant should have the courage and determination to do the right thing, regardless of the consequences. Considering the welfare of the patient is always the best starting point. These qualities provide an important guideline to the daily behavior of the ophthalmic assistant who works with the public. An assistant can review the effectiveness evaluation to see how he or she rates ( Box 6.4 ). Self-evaluation can be important.

Box 6.4

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