Could Your Practice Be Better?
June 2005
H ow many of us think of ourselves as servants of our patients? How many of us strive to exceed the expectations of our patients? How often do we reflect on our role as leaders within our offices and the implications for leadership?
There are principles — or basic truths — related to excellent service in health care. If we espouse these principles with conviction and commitment, we will develop practices that deliver excellent service. In this article, we propose 10 basic principles of service excellence and provide tips for understanding them and implementing them within your practices. Many more tips for implementation exist than these, but we hope you will use them to guide behavior and as a springboard for discussion among office co-workers.
Principle 1: We work in a service industry.
Healthcare is a pure service industry. Unlike manufacturing or agrarian industries, we make no tangible product. We produce no goods. We grow nothing. What we offer cannot be picked off a shelf at Wal-Mart nor can it be ordered “online” and delivered. All that we have to offer is our service.
TIP Teach your staff this principle first. Raise their awareness. It is surprising how many people in health care don’t realize or have not thought about this fact. Our personal service is our product.
Principle 2: We should strive to provide the best service.
Patients have choices. We all want our patients to choose us. If our product is “service,” then it follows that patients will choose us based on whether it is their belief that we provide the best service. The operative word is “choose.”
TIP There is service and there is best service. Pick an industry outside of health care — clothing merchandising or restaurants, for example — and ask your staff to describe their best and worst experiences. Most of the experiences will center on how they were treated person to person. Even in these industries where there are tangible products – clothing and food – we relate the quality of the experience to our interactions with people.
TIP Usually, in this exercise, co-workers focus on worst experiences. If this happens, after a while refocus the discussion on “best” experiences. End on the positive.
Principle 3: Service that simply meets expectations usually goes unnoticed.
Service is noticed when it either exceeds or fails to meet expectations. This principle is perhaps the most important. Our brains are bombarded with a myriad of sensations and experiences each day and most are quickly forgotten. Usually, we remember events, often unexpected, that trigger an emotional response. To a wine connoisseur it might be a very special wine. To the moviegoer, certain scenes remain vivid while others are forgotten. Similarly, a particularly rude clerk in a department store might be all that we remember 1 or 2 weeks after a shopping trip. This is equally true in health care. Our service is only memorable when it exceeds, or fails to meet, what our patients expect.
TIP Using the experiences described by your employees, ask them why they remember the experiences. It will be apparent that each of their experiences was remembered because of emotions such as anger, happiness or love that the experiences triggered.
TIP Often the reason a good experience is remembered by the recipient of the service is because the provider of the service went above and beyond what was expected.
A little bit of “follow-up” is probably the easiest way to transform an ordinary experience into something that is extraordinary. When somebody follows-up on his or her work, it sends the message that he or she cares about quality, thoroughness, and even more specifically, about the individual he or she is serving. Call a percentage of your patients. Follow-up on a routine case takes little time, yet you will create an indelible impression in the mind of the patient. In terms of a “value equation,” it is one of the biggest gains that can be made while requiring minimal time and effort.
Principle 4: Exceed the expectations of patients.
The logic is quite simple. If we exceed the expectations of our patients, they will recognize or remember our service (care) as “the best,” and they will choose us in the future for their dermatological care. They will be more likely to become loyal patients. Loyalty is an important concept to understand. In his article, “A Satisfied Customer Isn’t Enough,” Thomas Stewart described the important difference from a business perspective between loyal and satisfied customers. Of customers who described themselves as “satisfied,” 80% indicated that they would switch to a competitor if the competitor were more convenient.1
On the other hand, loyal customers, as defined by Frederick Reichheld in his book The Loyalty Effect, are those who would remain with the service provider despite inconvenience of location or even service shortfalls.
Loyal customers are also more likely to tell friends and family about the service they received thereby amplifying their effect on business.2 Loyalty derives from perceived exceptional service. Our goal is patient loyalty, not the absence of complaints.
TIP The number-one reason that people don’t come back for service in health care is a feeling that those who care for them are disinterested in them. How often have we felt or heard, “I’m just a number” or “I’m just next in line”?
TIP We sense when we are being treated as an individual. This leads to loyalty. “He cares about me and my problems.” Our goal should be that each of our patients leaves the office with that special feeling. Such patients will return for service even if a competitor is more conveniently located or even if we have an occasional service shortfall. And loyal patients will tell friends and family about our service.
TIP Start person-to-person; and end person-to-person. Personalized and emotion-filled memorable service is our goal. All staff — secretary, receptionist, nurse and doctor — should begin the patient interaction with an introduction by name, a smile and personal warmth. Begin as if you were meeting a neighbor or new friend. End all interactions with a smile, a thank you, and/or “is there anything else I can do for you?” Discuss and role-play these interactions with staff. Remember, even administrative assistants can “smile on the phone” through tone of voice.
TIP When you must spend time at the computer or writing in the chart, in other words away from personal interaction, excuse yourself. For example before you look away and begin to type or write, the doctor or nurse might say, “Mrs. Jones excuse me for a moment while I update your medical record.”
Principle 5: We have good people working with us.
It is easy to blame service shortfalls on our co-workers. For example, we might think, “if only my receptionist weren’t so abrupt,” we would be perceived as providing better service. Or, “if only my partner weren’t so abrasive with the office staff,” then we could develop a culture of service excellence.
We often complain about our co-workers, but we rarely take positive initiative to actually work with them to elevate the level of service to our patients. People can, and will, do extraordinary things when they know their work is worthwhile. A desire for greatness, or excellence, exists within everybody. We have to be willing to take the harder, yet more rewarding, road of working to bring the best out in our people. It can be done.
TIP Set each other up for success by speaking positively about each other. Here are some examples of things to say to patients:
• Doctor: “Mrs. Jones, Nancy is going to put one of her great dressings on your wound, and then she’ll explain to you how you can reapply it easily at home.”
• Doctor: “Mrs. Jones, if you ever have any problems with your dressing, call our office and ask to speak to Nancy. She’s the expert.”
• Nurse:“Mrs. Jones, I sense that you’re a bit nervous but you’ll love Dr. Smith. She’s so kind and gentle. She’s great.”
• Administrative Assistant: “Mrs. Jones, thanks so much for calling for an appointment. I think you’ll love our office staff. They’re wonderful.”
Principle 6: Service excellence can be learned.
While it might be true that some people have better inherent “people” skills, many of these skills are learned behaviors. Service excellence is a skill that can be taught, developed and learned. It is not genetic.
For example, physician-patient communication is a skill set that can be taught. The Bayer Institute for Health Care Communication demonstrates through research data that improved communication skills can be learned and continuously improved upon. Commu-nication is analogous to a procedure that can be taught and then mastered through practice.3 Similarly, office personnel can learn behaviors that please patients, family members and co-workers.
TIP Certain behaviors are more pleasing to patients than others. How we answer the phone; what name we use when we refer to patients; how we introduce ourselves to patients; what we say when we ask them to undress for an examination — all of these interactions and many more can be made explicit or can be agreed upon by staff. Consistently excellent personal service occurs by design with explicit standards of behavior delivered by a well-trained staff.
Here are some examples of excellent personal service:
• Administrative Assistant: “Good morning. Dr. Smith’s office,” is more pleasing than “Dermatology.”
• Receptionist: “Good afternoon, how may I help you?” sounds better than “Next, please.”
• Nurse: “Mrs. Jones, would you mind putting this gown on so that Dr. Smith can examine your back? Great. You can leave your bra on. Slip the gown on this way. It ties in the back. I’ll lock the door for your privacy. Please just crack the door open like this when you’re ready for Dr. Smith,” is more explicit and sounds better than “Mrs. Jones, put this gown on and Dr. Smith will be in shortly.”
• Doctor: Prepare your entrance. Pause at the door. Gather your thoughts for a moment. Then, walk in with calmness yet also with energy and a smile. Avoid that rushed appearance. Convey personal warmth. Show each patient that you are glad to see him or her.
These and many other behaviors should become office standards. They should be agreed upon, written, practiced, reinforced and revised as necessary. In time, they will become second nature and part of the office culture.
Principle 7: Team work improves service.
Service improvement occurs best at the work unit level by teams of individuals who best understand the issues of their work environment. Service excellence is not static. Patient expectations change over time just as our expectations change. Once we experience a service, we become familiar or accustomed to it. As we improve service delivery, patients have higher expectations and we need to continuously improve in order to deliver exceptional care. Such improvement efforts are best accomplished by teamwork where everyone is working toward a common goal.
TIP Discuss these examples to help staff understand that service is a moving target.
1. The “no-questions-asked” return policy of through-the-mail merchants. This policy has almost become an industry standard. Yet, not long ago it was exceptional. We have now come to expect it so that it is no longer exceptional. What will merchants do next to make their service better than the competition?
2. Credit card pay-at-the-pump. A convenience that several years ago we sought out. Now industry standard. In fact, we avoid stations that do not offer it and become a little upset when we must see the cashier inside.
3. Doctors’ offices with up-to-date magazines. While once a novelty, now this has become standard and expected.
TIP Involve the entire staff regularly in discussions to improve service. Value everyone’s input. In the arena of service improvement efforts, everyone in the office should be on a level playing field. Since we all receive service, we are all experts. Involving the entire office staff in regular discussions on service improvement builds teamwork and gives employees a feeling of ownership. Staff will begin to think about ways to improve the office while receiving services elsewhere. While not all suggestions will be implemented, it is important that all suggestions be heard.
TIP Consider using a BSSB — best service suggestion box. Some employees will feel more comfortable making suggestions in private with the doctor or in a written format than in a group discussion. Acknowledge all suggestions either in a group discussion or in private. Feedback is essential to building a culture that encourages continuous service improvement suggestions.
TIP Cynicism, sarcasm and blaming are weaknesses of human character that absolve oneself from the personal responsibility of solving problems together. Don’t be cynical. Don’t be sarcastic. And don’t blame others for service shortfalls. Likewise, don’t allow such behavior by co-workers. Teach your staff that we will solve problems together.
Principle 8: Customer feedback is essential.
Measurement of service from the customer’s perspective and timely feedback of data to the staff should drive process improvement. We cannot have an accurate understanding of how we are perceived by our patients without asking them. We all have “blind spots.”
Systematic measurement of service will help us identify areas of service strength and areas in which our patients perceive we can improve. Ideally, the measurement tool should be benchmarked against a database of similar practices so that we can compare our practices with others. Inherent in any survey tool are biases, and comparing practices that use the same methodology can provide valuable insight. For example, we might be deluded into thinking that a 90% good or excellent rating is “good enough.” If, however, comparative ranking indicated that such scores placed our practice in the 25th percentile in patient satisfaction, we would be less satisfied. Ideally, the tool would measure specific areas such as physician or provider perceived quality and communication skills, waiting times, convenience in making appointments, confidentiality, and nursing skill. This data can serve as a catalyst for the office staff to brainstorm and implement processes for improvement.
TIP On a scale of 1 to 5, with 1 being poor and 5 being excellent, most patients will rate our practices a 4 or a 5. But, you can’t tell the 4s from the 5s without measuring. Service that is good is not good enough. The patients who rate our service as good or very good are not the loyal ones. They are satisfied, but given a more convenient alternative might switch providers. Loyal patients, those who rate us as excellent or exceptional, are the goal.
TIP The absence of complaints does not mean the practice is exceptional. In fact, it doesn’t even mean it’s above average. Consumer research shows that 96% of unhappy customers do not complain.
TIP Solving patient complaints is not the same as working on service excellence. We cannot ignore complaints and must act on them, but spending most of our time on complaints is like trying to extinguish brush fires. Devote most of your time discussing ways to excel beyond patient expectations.
TIP Service recovery can be an opportunity for service distinction. When dealing with a complaint, decide if you have an opportunity to exceed expectations. A sincere apology by the doctor from his home to the patient’s home in the evening – or even a home visit – shows genuine remorse and specific interest in that patient as valued person.
Principle 9: Physicians must lead.
Physicians are the leaders in healthcare. Our office personnel look to us for direction. We cannot abdicate the responsibility for service improvement to others. We cannot send our nurses, administrative assistants and receptionists to “charm school” and expect that our offices will provide exceptional service. Just as we lead the work team in the delivery of care through our technical expertise or diagnostic acumen, so too must we lead the healthcare team in the area of service improvement.
TIP A physician must model the behavior he or she desires in co-workers. If we want our co-workers to treat our patients as individuals, we must know and treat our employees as individuals. Do you know the hopes, fears, personal trials and tribulations of your co-workers? Do you understand that what they really want is to know that their work is worthwhile and is valued by you? Do your co-workers feel valued?
TIP Treat all patients with respect. If the physician rolls his eyes when a patient is particularly “difficult,” then the message to the office staff is that it’s acceptable to treat someone with disrespect. However, if the physician is empathetic to a particularly “difficult” patient, the staff learns that all patients deserve our kindness and respect.
TIP Treat all co-workers with respect and kindness. Treat them as well as you do your patients. Goethe, the German philosopher said, “If we treat people as they are, we make them worse. If we treat people as they ought to be we help them become what they are capable of becoming.” Treat your co-workers as they ought to be. Help them become the great service providers that they are capable of becoming.
TIP Greet all co-workers in the morning.
TIP Thank your co-workers at the end of the day.
TIP When your day is busier than usual, make a special point of acknowledging the extra effort made by the entire staff. Co-workers usually don’t mind “going the extra mile” if they know their work is worthwhile and appreciated.
Principle 10: Celebrate success rather than punish shortfalls.
Positive reinforcement of behavior is more effective than negative reinforcement in obtaining desired behavior on a consistent basis. It is more effective and certainly kinder to praise someone for doing something “right” rather than criticize him or her for doing something “wrong.” Praise raises self-esteem and positively reinforces that desired behavior. If praise is public — performed in an office meeting or within earshot of other employees — we can also amplify its effect by reinforcing desired behaviors in the minds of other co-workers. On the other hand, criticism is often hurtful and lowers self-esteem, and if done in public can adversely affect morale. Even “constructive criticism” is rarely perceived as constructive.
TIP As you observe co-workers performing a specific behavior well, compliment them. For example, “Nancy, I loved the way you introduced yourself to Mr. Jones. Your smile, your touch with a handshake, using your first name and calling him Mr. Jones is just the way we want to do it.” Nancy will know that you value her work, you appreciate the job she’s doing, and will likely repeat this behavior with subsequent patients. In addition, praising Nancy within earshot of other co-workers spreads the word about what pleases and is valued by you.
However, if you had corrected her for calling another patient “Bob” and not introducing herself, it is less likely that the desired behavior would be consistently repeated and Nancy would have felt less valued.
TIPCelebrate in public. Correct in private. Be sensitive enough to never embarrass a co-worker. When correcting, start with a positive statement and end with a positive statement about the co-worker. Then, when you observe an improvement in the desired behavior, affirm this to your co-worker. If you genuinely care about your co-workers’ feelings, they will genuinely care about your patients’ feelings.
Striving for Excellence
In health care we serve others. We serve their healthcare needs. The extent to which we serve them extraordinarily well combined with prudent business practice will determine the level and will measure of our success. Service excellence can be attained in any office, but it will require an understanding of these principles and a willingness to work together for greatness.
H ow many of us think of ourselves as servants of our patients? How many of us strive to exceed the expectations of our patients? How often do we reflect on our role as leaders within our offices and the implications for leadership?
There are principles — or basic truths — related to excellent service in health care. If we espouse these principles with conviction and commitment, we will develop practices that deliver excellent service. In this article, we propose 10 basic principles of service excellence and provide tips for understanding them and implementing them within your practices. Many more tips for implementation exist than these, but we hope you will use them to guide behavior and as a springboard for discussion among office co-workers.
Principle 1: We work in a service industry.
Healthcare is a pure service industry. Unlike manufacturing or agrarian industries, we make no tangible product. We produce no goods. We grow nothing. What we offer cannot be picked off a shelf at Wal-Mart nor can it be ordered “online” and delivered. All that we have to offer is our service.
TIP Teach your staff this principle first. Raise their awareness. It is surprising how many people in health care don’t realize or have not thought about this fact. Our personal service is our product.
Principle 2: We should strive to provide the best service.
Patients have choices. We all want our patients to choose us. If our product is “service,” then it follows that patients will choose us based on whether it is their belief that we provide the best service. The operative word is “choose.”
TIP There is service and there is best service. Pick an industry outside of health care — clothing merchandising or restaurants, for example — and ask your staff to describe their best and worst experiences. Most of the experiences will center on how they were treated person to person. Even in these industries where there are tangible products – clothing and food – we relate the quality of the experience to our interactions with people.
TIP Usually, in this exercise, co-workers focus on worst experiences. If this happens, after a while refocus the discussion on “best” experiences. End on the positive.
Principle 3: Service that simply meets expectations usually goes unnoticed.
Service is noticed when it either exceeds or fails to meet expectations. This principle is perhaps the most important. Our brains are bombarded with a myriad of sensations and experiences each day and most are quickly forgotten. Usually, we remember events, often unexpected, that trigger an emotional response. To a wine connoisseur it might be a very special wine. To the moviegoer, certain scenes remain vivid while others are forgotten. Similarly, a particularly rude clerk in a department store might be all that we remember 1 or 2 weeks after a shopping trip. This is equally true in health care. Our service is only memorable when it exceeds, or fails to meet, what our patients expect.
TIP Using the experiences described by your employees, ask them why they remember the experiences. It will be apparent that each of their experiences was remembered because of emotions such as anger, happiness or love that the experiences triggered.
TIP Often the reason a good experience is remembered by the recipient of the service is because the provider of the service went above and beyond what was expected.
A little bit of “follow-up” is probably the easiest way to transform an ordinary experience into something that is extraordinary. When somebody follows-up on his or her work, it sends the message that he or she cares about quality, thoroughness, and even more specifically, about the individual he or she is serving. Call a percentage of your patients. Follow-up on a routine case takes little time, yet you will create an indelible impression in the mind of the patient. In terms of a “value equation,” it is one of the biggest gains that can be made while requiring minimal time and effort.
Principle 4: Exceed the expectations of patients.
The logic is quite simple. If we exceed the expectations of our patients, they will recognize or remember our service (care) as “the best,” and they will choose us in the future for their dermatological care. They will be more likely to become loyal patients. Loyalty is an important concept to understand. In his article, “A Satisfied Customer Isn’t Enough,” Thomas Stewart described the important difference from a business perspective between loyal and satisfied customers. Of customers who described themselves as “satisfied,” 80% indicated that they would switch to a competitor if the competitor were more convenient.1
On the other hand, loyal customers, as defined by Frederick Reichheld in his book The Loyalty Effect, are those who would remain with the service provider despite inconvenience of location or even service shortfalls.
Loyal customers are also more likely to tell friends and family about the service they received thereby amplifying their effect on business.2 Loyalty derives from perceived exceptional service. Our goal is patient loyalty, not the absence of complaints.
TIP The number-one reason that people don’t come back for service in health care is a feeling that those who care for them are disinterested in them. How often have we felt or heard, “I’m just a number” or “I’m just next in line”?
TIP We sense when we are being treated as an individual. This leads to loyalty. “He cares about me and my problems.” Our goal should be that each of our patients leaves the office with that special feeling. Such patients will return for service even if a competitor is more conveniently located or even if we have an occasional service shortfall. And loyal patients will tell friends and family about our service.
TIP Start person-to-person; and end person-to-person. Personalized and emotion-filled memorable service is our goal. All staff — secretary, receptionist, nurse and doctor — should begin the patient interaction with an introduction by name, a smile and personal warmth. Begin as if you were meeting a neighbor or new friend. End all interactions with a smile, a thank you, and/or “is there anything else I can do for you?” Discuss and role-play these interactions with staff. Remember, even administrative assistants can “smile on the phone” through tone of voice.
TIP When you must spend time at the computer or writing in the chart, in other words away from personal interaction, excuse yourself. For example before you look away and begin to type or write, the doctor or nurse might say, “Mrs. Jones excuse me for a moment while I update your medical record.”
Principle 5: We have good people working with us.
It is easy to blame service shortfalls on our co-workers. For example, we might think, “if only my receptionist weren’t so abrupt,” we would be perceived as providing better service. Or, “if only my partner weren’t so abrasive with the office staff,” then we could develop a culture of service excellence.
We often complain about our co-workers, but we rarely take positive initiative to actually work with them to elevate the level of service to our patients. People can, and will, do extraordinary things when they know their work is worthwhile. A desire for greatness, or excellence, exists within everybody. We have to be willing to take the harder, yet more rewarding, road of working to bring the best out in our people. It can be done.
TIP Set each other up for success by speaking positively about each other. Here are some examples of things to say to patients:
• Doctor: “Mrs. Jones, Nancy is going to put one of her great dressings on your wound, and then she’ll explain to you how you can reapply it easily at home.”
• Doctor: “Mrs. Jones, if you ever have any problems with your dressing, call our office and ask to speak to Nancy. She’s the expert.”
• Nurse:“Mrs. Jones, I sense that you’re a bit nervous but you’ll love Dr. Smith. She’s so kind and gentle. She’s great.”
• Administrative Assistant: “Mrs. Jones, thanks so much for calling for an appointment. I think you’ll love our office staff. They’re wonderful.”
Principle 6: Service excellence can be learned.
While it might be true that some people have better inherent “people” skills, many of these skills are learned behaviors. Service excellence is a skill that can be taught, developed and learned. It is not genetic.
For example, physician-patient communication is a skill set that can be taught. The Bayer Institute for Health Care Communication demonstrates through research data that improved communication skills can be learned and continuously improved upon. Commu-nication is analogous to a procedure that can be taught and then mastered through practice.3 Similarly, office personnel can learn behaviors that please patients, family members and co-workers.
TIP Certain behaviors are more pleasing to patients than others. How we answer the phone; what name we use when we refer to patients; how we introduce ourselves to patients; what we say when we ask them to undress for an examination — all of these interactions and many more can be made explicit or can be agreed upon by staff. Consistently excellent personal service occurs by design with explicit standards of behavior delivered by a well-trained staff.
Here are some examples of excellent personal service:
• Administrative Assistant: “Good morning. Dr. Smith’s office,” is more pleasing than “Dermatology.”
• Receptionist: “Good afternoon, how may I help you?” sounds better than “Next, please.”
• Nurse: “Mrs. Jones, would you mind putting this gown on so that Dr. Smith can examine your back? Great. You can leave your bra on. Slip the gown on this way. It ties in the back. I’ll lock the door for your privacy. Please just crack the door open like this when you’re ready for Dr. Smith,” is more explicit and sounds better than “Mrs. Jones, put this gown on and Dr. Smith will be in shortly.”
• Doctor: Prepare your entrance. Pause at the door. Gather your thoughts for a moment. Then, walk in with calmness yet also with energy and a smile. Avoid that rushed appearance. Convey personal warmth. Show each patient that you are glad to see him or her.
These and many other behaviors should become office standards. They should be agreed upon, written, practiced, reinforced and revised as necessary. In time, they will become second nature and part of the office culture.
Principle 7: Team work improves service.
Service improvement occurs best at the work unit level by teams of individuals who best understand the issues of their work environment. Service excellence is not static. Patient expectations change over time just as our expectations change. Once we experience a service, we become familiar or accustomed to it. As we improve service delivery, patients have higher expectations and we need to continuously improve in order to deliver exceptional care. Such improvement efforts are best accomplished by teamwork where everyone is working toward a common goal.
TIP Discuss these examples to help staff understand that service is a moving target.
1. The “no-questions-asked” return policy of through-the-mail merchants. This policy has almost become an industry standard. Yet, not long ago it was exceptional. We have now come to expect it so that it is no longer exceptional. What will merchants do next to make their service better than the competition?
2. Credit card pay-at-the-pump. A convenience that several years ago we sought out. Now industry standard. In fact, we avoid stations that do not offer it and become a little upset when we must see the cashier inside.
3. Doctors’ offices with up-to-date magazines. While once a novelty, now this has become standard and expected.
TIP Involve the entire staff regularly in discussions to improve service. Value everyone’s input. In the arena of service improvement efforts, everyone in the office should be on a level playing field. Since we all receive service, we are all experts. Involving the entire office staff in regular discussions on service improvement builds teamwork and gives employees a feeling of ownership. Staff will begin to think about ways to improve the office while receiving services elsewhere. While not all suggestions will be implemented, it is important that all suggestions be heard.
TIP Consider using a BSSB — best service suggestion box. Some employees will feel more comfortable making suggestions in private with the doctor or in a written format than in a group discussion. Acknowledge all suggestions either in a group discussion or in private. Feedback is essential to building a culture that encourages continuous service improvement suggestions.
TIP Cynicism, sarcasm and blaming are weaknesses of human character that absolve oneself from the personal responsibility of solving problems together. Don’t be cynical. Don’t be sarcastic. And don’t blame others for service shortfalls. Likewise, don’t allow such behavior by co-workers. Teach your staff that we will solve problems together.
Principle 8: Customer feedback is essential.
Measurement of service from the customer’s perspective and timely feedback of data to the staff should drive process improvement. We cannot have an accurate understanding of how we are perceived by our patients without asking them. We all have “blind spots.”
Systematic measurement of service will help us identify areas of service strength and areas in which our patients perceive we can improve. Ideally, the measurement tool should be benchmarked against a database of similar practices so that we can compare our practices with others. Inherent in any survey tool are biases, and comparing practices that use the same methodology can provide valuable insight. For example, we might be deluded into thinking that a 90% good or excellent rating is “good enough.” If, however, comparative ranking indicated that such scores placed our practice in the 25th percentile in patient satisfaction, we would be less satisfied. Ideally, the tool would measure specific areas such as physician or provider perceived quality and communication skills, waiting times, convenience in making appointments, confidentiality, and nursing skill. This data can serve as a catalyst for the office staff to brainstorm and implement processes for improvement.
TIP On a scale of 1 to 5, with 1 being poor and 5 being excellent, most patients will rate our practices a 4 or a 5. But, you can’t tell the 4s from the 5s without measuring. Service that is good is not good enough. The patients who rate our service as good or very good are not the loyal ones. They are satisfied, but given a more convenient alternative might switch providers. Loyal patients, those who rate us as excellent or exceptional, are the goal.
TIP The absence of complaints does not mean the practice is exceptional. In fact, it doesn’t even mean it’s above average. Consumer research shows that 96% of unhappy customers do not complain.
TIP Solving patient complaints is not the same as working on service excellence. We cannot ignore complaints and must act on them, but spending most of our time on complaints is like trying to extinguish brush fires. Devote most of your time discussing ways to excel beyond patient expectations.
TIP Service recovery can be an opportunity for service distinction. When dealing with a complaint, decide if you have an opportunity to exceed expectations. A sincere apology by the doctor from his home to the patient’s home in the evening – or even a home visit – shows genuine remorse and specific interest in that patient as valued person.
Principle 9: Physicians must lead.
Physicians are the leaders in healthcare. Our office personnel look to us for direction. We cannot abdicate the responsibility for service improvement to others. We cannot send our nurses, administrative assistants and receptionists to “charm school” and expect that our offices will provide exceptional service. Just as we lead the work team in the delivery of care through our technical expertise or diagnostic acumen, so too must we lead the healthcare team in the area of service improvement.
TIP A physician must model the behavior he or she desires in co-workers. If we want our co-workers to treat our patients as individuals, we must know and treat our employees as individuals. Do you know the hopes, fears, personal trials and tribulations of your co-workers? Do you understand that what they really want is to know that their work is worthwhile and is valued by you? Do your co-workers feel valued?
TIP Treat all patients with respect. If the physician rolls his eyes when a patient is particularly “difficult,” then the message to the office staff is that it’s acceptable to treat someone with disrespect. However, if the physician is empathetic to a particularly “difficult” patient, the staff learns that all patients deserve our kindness and respect.
TIP Treat all co-workers with respect and kindness. Treat them as well as you do your patients. Goethe, the German philosopher said, “If we treat people as they are, we make them worse. If we treat people as they ought to be we help them become what they are capable of becoming.” Treat your co-workers as they ought to be. Help them become the great service providers that they are capable of becoming.
TIP Greet all co-workers in the morning.
TIP Thank your co-workers at the end of the day.
TIP When your day is busier than usual, make a special point of acknowledging the extra effort made by the entire staff. Co-workers usually don’t mind “going the extra mile” if they know their work is worthwhile and appreciated.
Principle 10: Celebrate success rather than punish shortfalls.
Positive reinforcement of behavior is more effective than negative reinforcement in obtaining desired behavior on a consistent basis. It is more effective and certainly kinder to praise someone for doing something “right” rather than criticize him or her for doing something “wrong.” Praise raises self-esteem and positively reinforces that desired behavior. If praise is public — performed in an office meeting or within earshot of other employees — we can also amplify its effect by reinforcing desired behaviors in the minds of other co-workers. On the other hand, criticism is often hurtful and lowers self-esteem, and if done in public can adversely affect morale. Even “constructive criticism” is rarely perceived as constructive.
TIP As you observe co-workers performing a specific behavior well, compliment them. For example, “Nancy, I loved the way you introduced yourself to Mr. Jones. Your smile, your touch with a handshake, using your first name and calling him Mr. Jones is just the way we want to do it.” Nancy will know that you value her work, you appreciate the job she’s doing, and will likely repeat this behavior with subsequent patients. In addition, praising Nancy within earshot of other co-workers spreads the word about what pleases and is valued by you.
However, if you had corrected her for calling another patient “Bob” and not introducing herself, it is less likely that the desired behavior would be consistently repeated and Nancy would have felt less valued.
TIPCelebrate in public. Correct in private. Be sensitive enough to never embarrass a co-worker. When correcting, start with a positive statement and end with a positive statement about the co-worker. Then, when you observe an improvement in the desired behavior, affirm this to your co-worker. If you genuinely care about your co-workers’ feelings, they will genuinely care about your patients’ feelings.
Striving for Excellence
In health care we serve others. We serve their healthcare needs. The extent to which we serve them extraordinarily well combined with prudent business practice will determine the level and will measure of our success. Service excellence can be attained in any office, but it will require an understanding of these principles and a willingness to work together for greatness.
H ow many of us think of ourselves as servants of our patients? How many of us strive to exceed the expectations of our patients? How often do we reflect on our role as leaders within our offices and the implications for leadership?
There are principles — or basic truths — related to excellent service in health care. If we espouse these principles with conviction and commitment, we will develop practices that deliver excellent service. In this article, we propose 10 basic principles of service excellence and provide tips for understanding them and implementing them within your practices. Many more tips for implementation exist than these, but we hope you will use them to guide behavior and as a springboard for discussion among office co-workers.
Principle 1: We work in a service industry.
Healthcare is a pure service industry. Unlike manufacturing or agrarian industries, we make no tangible product. We produce no goods. We grow nothing. What we offer cannot be picked off a shelf at Wal-Mart nor can it be ordered “online” and delivered. All that we have to offer is our service.
TIP Teach your staff this principle first. Raise their awareness. It is surprising how many people in health care don’t realize or have not thought about this fact. Our personal service is our product.
Principle 2: We should strive to provide the best service.
Patients have choices. We all want our patients to choose us. If our product is “service,” then it follows that patients will choose us based on whether it is their belief that we provide the best service. The operative word is “choose.”
TIP There is service and there is best service. Pick an industry outside of health care — clothing merchandising or restaurants, for example — and ask your staff to describe their best and worst experiences. Most of the experiences will center on how they were treated person to person. Even in these industries where there are tangible products – clothing and food – we relate the quality of the experience to our interactions with people.
TIP Usually, in this exercise, co-workers focus on worst experiences. If this happens, after a while refocus the discussion on “best” experiences. End on the positive.
Principle 3: Service that simply meets expectations usually goes unnoticed.
Service is noticed when it either exceeds or fails to meet expectations. This principle is perhaps the most important. Our brains are bombarded with a myriad of sensations and experiences each day and most are quickly forgotten. Usually, we remember events, often unexpected, that trigger an emotional response. To a wine connoisseur it might be a very special wine. To the moviegoer, certain scenes remain vivid while others are forgotten. Similarly, a particularly rude clerk in a department store might be all that we remember 1 or 2 weeks after a shopping trip. This is equally true in health care. Our service is only memorable when it exceeds, or fails to meet, what our patients expect.
TIP Using the experiences described by your employees, ask them why they remember the experiences. It will be apparent that each of their experiences was remembered because of emotions such as anger, happiness or love that the experiences triggered.
TIP Often the reason a good experience is remembered by the recipient of the service is because the provider of the service went above and beyond what was expected.
A little bit of “follow-up” is probably the easiest way to transform an ordinary experience into something that is extraordinary. When somebody follows-up on his or her work, it sends the message that he or she cares about quality, thoroughness, and even more specifically, about the individual he or she is serving. Call a percentage of your patients. Follow-up on a routine case takes little time, yet you will create an indelible impression in the mind of the patient. In terms of a “value equation,” it is one of the biggest gains that can be made while requiring minimal time and effort.
Principle 4: Exceed the expectations of patients.
The logic is quite simple. If we exceed the expectations of our patients, they will recognize or remember our service (care) as “the best,” and they will choose us in the future for their dermatological care. They will be more likely to become loyal patients. Loyalty is an important concept to understand. In his article, “A Satisfied Customer Isn’t Enough,” Thomas Stewart described the important difference from a business perspective between loyal and satisfied customers. Of customers who described themselves as “satisfied,” 80% indicated that they would switch to a competitor if the competitor were more convenient.1
On the other hand, loyal customers, as defined by Frederick Reichheld in his book The Loyalty Effect, are those who would remain with the service provider despite inconvenience of location or even service shortfalls.
Loyal customers are also more likely to tell friends and family about the service they received thereby amplifying their effect on business.2 Loyalty derives from perceived exceptional service. Our goal is patient loyalty, not the absence of complaints.
TIP The number-one reason that people don’t come back for service in health care is a feeling that those who care for them are disinterested in them. How often have we felt or heard, “I’m just a number” or “I’m just next in line”?
TIP We sense when we are being treated as an individual. This leads to loyalty. “He cares about me and my problems.” Our goal should be that each of our patients leaves the office with that special feeling. Such patients will return for service even if a competitor is more conveniently located or even if we have an occasional service shortfall. And loyal patients will tell friends and family about our service.
TIP Start person-to-person; and end person-to-person. Personalized and emotion-filled memorable service is our goal. All staff — secretary, receptionist, nurse and doctor — should begin the patient interaction with an introduction by name, a smile and personal warmth. Begin as if you were meeting a neighbor or new friend. End all interactions with a smile, a thank you, and/or “is there anything else I can do for you?” Discuss and role-play these interactions with staff. Remember, even administrative assistants can “smile on the phone” through tone of voice.
TIP When you must spend time at the computer or writing in the chart, in other words away from personal interaction, excuse yourself. For example before you look away and begin to type or write, the doctor or nurse might say, “Mrs. Jones excuse me for a moment while I update your medical record.”
Principle 5: We have good people working with us.
It is easy to blame service shortfalls on our co-workers. For example, we might think, “if only my receptionist weren’t so abrupt,” we would be perceived as providing better service. Or, “if only my partner weren’t so abrasive with the office staff,” then we could develop a culture of service excellence.
We often complain about our co-workers, but we rarely take positive initiative to actually work with them to elevate the level of service to our patients. People can, and will, do extraordinary things when they know their work is worthwhile. A desire for greatness, or excellence, exists within everybody. We have to be willing to take the harder, yet more rewarding, road of working to bring the best out in our people. It can be done.
TIP Set each other up for success by speaking positively about each other. Here are some examples of things to say to patients:
• Doctor: “Mrs. Jones, Nancy is going to put one of her great dressings on your wound, and then she’ll explain to you how you can reapply it easily at home.”
• Doctor: “Mrs. Jones, if you ever have any problems with your dressing, call our office and ask to speak to Nancy. She’s the expert.”
• Nurse:“Mrs. Jones, I sense that you’re a bit nervous but you’ll love Dr. Smith. She’s so kind and gentle. She’s great.”
• Administrative Assistant: “Mrs. Jones, thanks so much for calling for an appointment. I think you’ll love our office staff. They’re wonderful.”
Principle 6: Service excellence can be learned.
While it might be true that some people have better inherent “people” skills, many of these skills are learned behaviors. Service excellence is a skill that can be taught, developed and learned. It is not genetic.
For example, physician-patient communication is a skill set that can be taught. The Bayer Institute for Health Care Communication demonstrates through research data that improved communication skills can be learned and continuously improved upon. Commu-nication is analogous to a procedure that can be taught and then mastered through practice.3 Similarly, office personnel can learn behaviors that please patients, family members and co-workers.
TIP Certain behaviors are more pleasing to patients than others. How we answer the phone; what name we use when we refer to patients; how we introduce ourselves to patients; what we say when we ask them to undress for an examination — all of these interactions and many more can be made explicit or can be agreed upon by staff. Consistently excellent personal service occurs by design with explicit standards of behavior delivered by a well-trained staff.
Here are some examples of excellent personal service:
• Administrative Assistant: “Good morning. Dr. Smith’s office,” is more pleasing than “Dermatology.”
• Receptionist: “Good afternoon, how may I help you?” sounds better than “Next, please.”
• Nurse: “Mrs. Jones, would you mind putting this gown on so that Dr. Smith can examine your back? Great. You can leave your bra on. Slip the gown on this way. It ties in the back. I’ll lock the door for your privacy. Please just crack the door open like this when you’re ready for Dr. Smith,” is more explicit and sounds better than “Mrs. Jones, put this gown on and Dr. Smith will be in shortly.”
• Doctor: Prepare your entrance. Pause at the door. Gather your thoughts for a moment. Then, walk in with calmness yet also with energy and a smile. Avoid that rushed appearance. Convey personal warmth. Show each patient that you are glad to see him or her.
These and many other behaviors should become office standards. They should be agreed upon, written, practiced, reinforced and revised as necessary. In time, they will become second nature and part of the office culture.
Principle 7: Team work improves service.
Service improvement occurs best at the work unit level by teams of individuals who best understand the issues of their work environment. Service excellence is not static. Patient expectations change over time just as our expectations change. Once we experience a service, we become familiar or accustomed to it. As we improve service delivery, patients have higher expectations and we need to continuously improve in order to deliver exceptional care. Such improvement efforts are best accomplished by teamwork where everyone is working toward a common goal.
TIP Discuss these examples to help staff understand that service is a moving target.
1. The “no-questions-asked” return policy of through-the-mail merchants. This policy has almost become an industry standard. Yet, not long ago it was exceptional. We have now come to expect it so that it is no longer exceptional. What will merchants do next to make their service better than the competition?
2. Credit card pay-at-the-pump. A convenience that several years ago we sought out. Now industry standard. In fact, we avoid stations that do not offer it and become a little upset when we must see the cashier inside.
3. Doctors’ offices with up-to-date magazines. While once a novelty, now this has become standard and expected.
TIP Involve the entire staff regularly in discussions to improve service. Value everyone’s input. In the arena of service improvement efforts, everyone in the office should be on a level playing field. Since we all receive service, we are all experts. Involving the entire office staff in regular discussions on service improvement builds teamwork and gives employees a feeling of ownership. Staff will begin to think about ways to improve the office while receiving services elsewhere. While not all suggestions will be implemented, it is important that all suggestions be heard.
TIP Consider using a BSSB — best service suggestion box. Some employees will feel more comfortable making suggestions in private with the doctor or in a written format than in a group discussion. Acknowledge all suggestions either in a group discussion or in private. Feedback is essential to building a culture that encourages continuous service improvement suggestions.
TIP Cynicism, sarcasm and blaming are weaknesses of human character that absolve oneself from the personal responsibility of solving problems together. Don’t be cynical. Don’t be sarcastic. And don’t blame others for service shortfalls. Likewise, don’t allow such behavior by co-workers. Teach your staff that we will solve problems together.
Principle 8: Customer feedback is essential.
Measurement of service from the customer’s perspective and timely feedback of data to the staff should drive process improvement. We cannot have an accurate understanding of how we are perceived by our patients without asking them. We all have “blind spots.”
Systematic measurement of service will help us identify areas of service strength and areas in which our patients perceive we can improve. Ideally, the measurement tool should be benchmarked against a database of similar practices so that we can compare our practices with others. Inherent in any survey tool are biases, and comparing practices that use the same methodology can provide valuable insight. For example, we might be deluded into thinking that a 90% good or excellent rating is “good enough.” If, however, comparative ranking indicated that such scores placed our practice in the 25th percentile in patient satisfaction, we would be less satisfied. Ideally, the tool would measure specific areas such as physician or provider perceived quality and communication skills, waiting times, convenience in making appointments, confidentiality, and nursing skill. This data can serve as a catalyst for the office staff to brainstorm and implement processes for improvement.
TIP On a scale of 1 to 5, with 1 being poor and 5 being excellent, most patients will rate our practices a 4 or a 5. But, you can’t tell the 4s from the 5s without measuring. Service that is good is not good enough. The patients who rate our service as good or very good are not the loyal ones. They are satisfied, but given a more convenient alternative might switch providers. Loyal patients, those who rate us as excellent or exceptional, are the goal.
TIP The absence of complaints does not mean the practice is exceptional. In fact, it doesn’t even mean it’s above average. Consumer research shows that 96% of unhappy customers do not complain.
TIP Solving patient complaints is not the same as working on service excellence. We cannot ignore complaints and must act on them, but spending most of our time on complaints is like trying to extinguish brush fires. Devote most of your time discussing ways to excel beyond patient expectations.
TIP Service recovery can be an opportunity for service distinction. When dealing with a complaint, decide if you have an opportunity to exceed expectations. A sincere apology by the doctor from his home to the patient’s home in the evening – or even a home visit – shows genuine remorse and specific interest in that patient as valued person.
Principle 9: Physicians must lead.
Physicians are the leaders in healthcare. Our office personnel look to us for direction. We cannot abdicate the responsibility for service improvement to others. We cannot send our nurses, administrative assistants and receptionists to “charm school” and expect that our offices will provide exceptional service. Just as we lead the work team in the delivery of care through our technical expertise or diagnostic acumen, so too must we lead the healthcare team in the area of service improvement.
TIP A physician must model the behavior he or she desires in co-workers. If we want our co-workers to treat our patients as individuals, we must know and treat our employees as individuals. Do you know the hopes, fears, personal trials and tribulations of your co-workers? Do you understand that what they really want is to know that their work is worthwhile and is valued by you? Do your co-workers feel valued?
TIP Treat all patients with respect. If the physician rolls his eyes when a patient is particularly “difficult,” then the message to the office staff is that it’s acceptable to treat someone with disrespect. However, if the physician is empathetic to a particularly “difficult” patient, the staff learns that all patients deserve our kindness and respect.
TIP Treat all co-workers with respect and kindness. Treat them as well as you do your patients. Goethe, the German philosopher said, “If we treat people as they are, we make them worse. If we treat people as they ought to be we help them become what they are capable of becoming.” Treat your co-workers as they ought to be. Help them become the great service providers that they are capable of becoming.
TIP Greet all co-workers in the morning.
TIP Thank your co-workers at the end of the day.
TIP When your day is busier than usual, make a special point of acknowledging the extra effort made by the entire staff. Co-workers usually don’t mind “going the extra mile” if they know their work is worthwhile and appreciated.
Principle 10: Celebrate success rather than punish shortfalls.
Positive reinforcement of behavior is more effective than negative reinforcement in obtaining desired behavior on a consistent basis. It is more effective and certainly kinder to praise someone for doing something “right” rather than criticize him or her for doing something “wrong.” Praise raises self-esteem and positively reinforces that desired behavior. If praise is public — performed in an office meeting or within earshot of other employees — we can also amplify its effect by reinforcing desired behaviors in the minds of other co-workers. On the other hand, criticism is often hurtful and lowers self-esteem, and if done in public can adversely affect morale. Even “constructive criticism” is rarely perceived as constructive.
TIP As you observe co-workers performing a specific behavior well, compliment them. For example, “Nancy, I loved the way you introduced yourself to Mr. Jones. Your smile, your touch with a handshake, using your first name and calling him Mr. Jones is just the way we want to do it.” Nancy will know that you value her work, you appreciate the job she’s doing, and will likely repeat this behavior with subsequent patients. In addition, praising Nancy within earshot of other co-workers spreads the word about what pleases and is valued by you.
However, if you had corrected her for calling another patient “Bob” and not introducing herself, it is less likely that the desired behavior would be consistently repeated and Nancy would have felt less valued.
TIPCelebrate in public. Correct in private. Be sensitive enough to never embarrass a co-worker. When correcting, start with a positive statement and end with a positive statement about the co-worker. Then, when you observe an improvement in the desired behavior, affirm this to your co-worker. If you genuinely care about your co-workers’ feelings, they will genuinely care about your patients’ feelings.
Striving for Excellence
In health care we serve others. We serve their healthcare needs. The extent to which we serve them extraordinarily well combined with prudent business practice will determine the level and will measure of our success. Service excellence can be attained in any office, but it will require an understanding of these principles and a willingness to work together for greatness.