Open Access Research article

Unannounced standardized patients: a promising method of assessing patient-centered care in your health care system

Sondra Zabar1*, Kathleen Hanley1, David Stevens2, Jessica Murphy2, Angela Burgess1, Adina Kalet1 and Colleen Gillespie1

Author Affiliations

1 Division of General Internal Medicine, Department of Medicine, New York University School of Medicine, 550 First Avenue, New York, NY 10016, USA

2 NYC Health & Hospitals Corporation, 346 Broadway #5, New York, NY 10013, USA

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BMC Health Services Research 2014, 14:157  doi:10.1186/1472-6963-14-157

Published: 5 April 2014



While unannounced standardized patients (USPs) have been used to assess physicians’ clinical skills in the ambulatory setting, they can also provide valuable information on patients’ experience of the health care setting beyond the physician encounter. This paper explores the use of USPs as a methodology for evaluating patient-centered care in the health care system.


USPs were trained to complete a behaviorally-anchored assessment of core dimensions of patient-centered care delivered within the clinical microsystem, including: 1) Medical assistants’ safe practices, quality of care, and responsiveness to patients; 2) ease of clinic navigation; and 3) the patient-centeredness of care provided by the physician. Descriptive data is provided on these three levels of patient-centeredness within the targeted clinical microsystem. Chi-square analyses were used to signal whether variations by teams within the clinical microsystem were likely to be due to chance or might reflect true differences in patient-centeredness of specific teams.


Sixty USP visits to 11 Primary Care teams were performed over an eight-month period (mean 5 visits/team; range 2–8). No medical assistants reported detecting an USP during the study period. USPs found the clinic easy to navigate and that teams were functioning well in 60% of visits. In 30% to 47% of visits, the physicians could have been more patient-centered. Medical assistants’ patient safety measures were poor: patient identity was confirmed in only 5% of visits and no USPs observed medical assistants wash their hands. Quality of care was relatively high for vital signs (e.g. blood pressure, weight and height), but low for depression screening, occurring in only 15% of visits. In most visits, medical assistants greeted the patient in a timely fashion but took time to fully explain matters in less than half of the visits and rarely introduced themselves. Physicians tried to help patients navigate the system in 62% of visits.


USP assessment captured actionable, critical, behaviorally-specific information on team and system performance in an urban community clinic. This methodology provides unique insight into the patient-centeredness and quality of care in medical settings.

Quality improvement; Unannounced standardized patients; Patient-centered care; Assessment; Quality of care