Kathleen D. Sanford

At a Glance

To promote better customer service, clinical and finance leaders should work as partners to:

  • Make customer service as important a goal as clinical quality  
  • Educate staff on better communication with patients and families  
  • Perform a root-cause analysis to identify problem trends  

As senior finance and clinical leaders in health care, we often meet people who want to share their experiences as patients. Some will tell us about the competence of their providers, the accuracy of their diagnoses, the appropriateness of their treatments, or whether they were cured or harmed. Such perceptions reflect the primary focus for most finance and clinical leaders these days: quality of care and safety. Other patients want to talk about their interactions with individual healthcare professionals, as well as the health system as a whole. These types of perceptions also are related to quality, but they could perhaps more aptly be described as "customer service" issues.

The New Customer-and a New Partnership

Unlike financial or quality issues, customer service hasn't been a major focus area for hospitals. One reason is that finance and clinical leaders may be somewhat unsure of who their primary customers are. Although patients may be consumers of our services, physicians have traditionally been considered hospitals' primary customers. Their historical role as the only individuals who could direct which services patients receive-and where they may receive them-has made them the major drivers of hospital revenues and costs.

In today's financially and clinically integrated health systems, hospitals are more likely to see physicians-whether they be employed or independent-not as customers, but as "partners." This partnership reflects the need for better coordination of care, which will be critical for hospitals to thrive in an era of healthcare reform.

There also will be the same critical need for better customer service. The government's value-based purchasing model includes weighted domains to calculate hospital payment levels. In this model, 70 percent of payment is based on clinical quality scores, while the remaining 30 percent is based on results of a standardized survey instrument, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), which collects and compares patients' perceptions of their hospital care (www.hcahps.org).

Thus, in today's world, patients have become the customers, and clinical and finance leaders must work together as partners to provide these customers with excellent quality of care and exemplary customer service.

The Impact of Customer Service

That said, it's important to remember that quality and customer service are not the same thing. The Centers for Medicare & Medicaid Services (CMS) considers HCAHPS scores as quality measures, but patient perceptions aren't reliable as valid predictors of quality, according to government figures. Data released by CMS in August 2011 show that 120 facilities with above average mortality rates for inpatients diagnosed with myocardial infarctions, heart failure, and pneumonia received high ratings on HCAHPS (www.hospitalcompare.hhs.gov).

So although those patients may not have known how to judge the clinical quality of their care, something at those organizations impressed them-and it could simply have been excellent customer service. The opposite also is possible: A patient who has received the very best clinical care with outstanding medical outcomes could be dissatisfied because of the perception that hospital staff were discourteous and dismissive of his or her feelings (Fields, R., Becker's Hospital Review, Oct. 1, 2010, www.beckershospitalreview.com/hospital-financial-and-business-news/why-high-technical-quality-might-not-mean-high-patient-satisfaction.html ). The discrepancy between measurable clinical results and patient perceptions illustrates the need for hospitals and their physician partners to consider how to provide better customer service in addition to high-quality care.


It might seem that improving patient perceptions of hospital experiences would be less challenging than improving clinical quality. Because hospitals know what the HCAHPS questions are-and because many of the questions address communication issues-why can't clinical and financial leaders simply tell nurses, physicians, admitting personnel, and other staff to communicate better with patients and families? And while they're at it, why don't they also emphasize the importance of keeping the place clean and quiet, and giving pain medications on time-two other HCAHPS measurements?

Unfortunately, it is not quite that simple. Good leaders know that just telling people to change doesn't work. And those who understand customer service realize that the HCAHPS questions don't capture the entire patient and family experience.

What's more, astute clinical and financial leaders recognize that the importance of customer service goes beyond HCAHPS. One reason to embrace better customer service is that it may help prevent litigation, because people are less likely to sue for poor clinical outcomes if they perceive their caregivers truly care about them. There are also financial advantages of having a brand that attracts business because of its reputation for excellence-in other words, consumers often perceive customer service as quality. Further, multiple studies have linked individual patient outcomes to the patient's perceptions of his or her care. (See, for example, "The Correlation Between Patient Satisfaction and Positive Clinical Outcomes," Studer Group, 2011, www.studergroup.com/dotCMS/KnowledgeAssetDetail?inode=251260).

How We Fail

Shouldn't it be second nature for healthcare staff to be kind, polite, considerate, and attentive to patients and their families? After all, these are the "caring professions." Even nonclinicians in hospitals frequently describe their desire to "make a difference" or "give back" or "help people." Yet we continue to hear from patients about less than ideal customer service in our organizations, from complaints about long waits, to a lack of communication from clinicians, to rude behavior in clinical and nonclinical departments alike. And poor bedside manner-commonly attributed to physicians but also an issue with other team members-has become a cliché.

To help address some of these issues, a couple recently made a $42 million dollar gift to the University of Chicago Medical Center for the express purpose of teaching physicians the importance of listening to patients and showing empathy. The donors referenced their own patient experiences as a reason to create an "institution devoted to improving medical students' handling of the physician-patient relationship" (Johnson, D., "A $42 Million Gift Aims at Improving Bedside Manner," The New York Times, Sept. 22, 2011, p. A14).

One of the challenges clinical and financial leaders face when trying to improve customer service is that patients don't differentiate between employees and independent medical staff members when they form their opinions about their hospital care. Even if most staff members treat customers well, it takes only one or two poor experiences with any team member to color the patient's perceptions of an entire healthcare system.

To address this problem, some hospitals and health systems offer employee education on simple basics, such as answering the phone or using scripts when communicating with the public. Some have begun hiring practices to assess and select candidates who have a predisposition for excellent customer service. Both are good strategies to increase the quality of communications or increase the chance of hiring well. However, they don't go far enough to transform an entire business into a customer-friendly place, especially if the institution has not been historically focused on patients as customers. Moreover, such solutions do not sufficiently involve physician partners, who should play an important role in advancing the organization's customer service objectives.

Diagnosing Problems

Elevating customer service to the same level of importance as clinical quality requires two things: data about current service levels and an honest look at hospital practices and cultural norms that may get in the way of service. The first requirement-data-is available through HCAHPS scores, organizational surveys, patient representative logs, and complaints to clinical and financial leaders.

The second requirement-identifying practices and behaviors that get in the way of service-demands a more analytical approach. And given that customer service is not exclusively a clinical issue, it is here that finance and clinical leaders can become effective partners in working to achieve customer service excellence. One of the best ways to identify the full range of practices and behaviors that impede customer service is to establish a task force-composed of physician, nurse, finance, human resources, and other health system leaders-to perform a root-cause analysis on identified problem trends. The team members should also understand the meaning of "root" causes, so that they don't focus on the symptoms of poor customer service instead of working to correct the causes.

For example, a symptom of a problem with hospital practices might be long waiting times in a clinic. If the delays are caused by hospital scheduling practices, a possible solution might be the use of tools based on queuing theory (Hall, R., Queuing Methods: For Services and Manufacturing, Englewood Cliffs, N.J.: Prentice-Hall, 1991). On the other hand, if the delays are caused by an employee attitude or culture problem, a different intervention is required.

In some cases, a root-cause analysis may uncover a cultural problem, reflecting the refrain, "That's just how it is in health care." In analyzing situations in which healthcare team members demonstrate complacency with poor service, the task force may uncover three related issues: a culture of entitlement, a lack of empathy, or poor employee satisfaction. Entitlement can be exhibited by individuals, such as a cardiac interventionist who habitually arrives well after the scheduled procedure time, apparently oblivious to the feelings of the anxious, prepped, and on-the-table patient. Entitlement also can be endemic of entire teams, such as the emergency department staff whose inattentiveness-or even incivility-gives the impression that nonemergent patients are a boring nuisance. The message to the patient? "We are more important than you. After all, you need us. We're here to save lives. So don't complain if you feel inconvenienced."

In terms of empathy, patients want to be cared for by people who possess the ability to understand and care about another person's experience. Unfortunately, it may be that some team members entered healthcare employment without empathy for others, perhaps driven by prestige, good incomes, and the availability of jobs. Others, including those who chose health care for altruistic reasons, may have lost the ability to empathize as a result of job burnout.

In fact, burnout is a root cause of poor patient satisfaction, owing to the correlation between how patients and staff feel about a healthcare organization. A 2009 study found that "hospital departments that have higher levels of employee satisfaction provide better experiences for patients" (Peltier, J., Dahl, A., and Mulhern, F., "The Relationship Between Employee Satisfaction and Hospital Patient Experiences," The Forum, April 2009). The researchers also stated that "physicians who are disrespectful to nonphysician staff, make negative comments, or treat the patient as if they are nonhuman, intangible entities lead to reduced engagement in nonphysician staff." In other words, the problem has a trickle-down effect.

Room for Improvement

Working to solve root causes of poor customer service in a hospital is more complicated than simply developing a strategy to improve HCAHPS scores. If physicians do not share in this effort, the hospital runs potential political risks, such as the alienation of some medical staff members who may still see themselves as the primary customers. Such risks underscore the importance of cultivating the partnership with physicians in working to improve customer service. There are also financial ramifications, such as the potential investment in coaching and training managers to appropriately address behavior that affects customer satisfaction. And if the root cause of poor patient satisfaction is poor employee satisfaction, a brand new root-cause analysis will be needed to determine the causes and possible solutions for that.

In short, the risks of not addressing root causes of patients' poor perceptions of service are substantial. These include lower revenues (because of low HCAHPS scores or loss of customers), a compromised reputation, suboptimal quality, and a failure to achieve the organization's mission. Making patient satisfaction a top organizational priority is necessary to mitigate these risks. And our organizations may even reap an additional reward if they develop a customer service culture that encompasses the entire enterprise, including physicians. The stories we may then hear from patients and families about their healthcare experiences are much more likely to make our physician partners and us proud-of our professions, our organizations, and our nation's entire healthcare system. Wouldn't that be wonderful?

Kathleen D. Sanford, RN, MA, DBA, FACHE, is senior vice president and chief nursing officer, Catholic Health Initiatives,Denver (kathleensanford@catholichealth.net).

Sidebar 1

Background on HCAHPS  

CMS has required hospitals to collect Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data since 2007. The HCAHPS survey measures 18 customer service perceptions on eight key topics: communication with physicians, communication with nurses, responsiveness of staff, pain management, communication about medications, discharge information, cleanliness of the
hospital, and quietness of the hospital environment. Hospitals must engage a government-approved vendor to query a sample of recently discharged patients on 27 questions. There are four screening questions and five demographic questions asked to obtain an adjusted patient mix and for analytic purposes.

Sidebar 2

Why Most Hospitals Perform Root-Cause Analyses  

A root cause analysis often is performed when a healthcare organization has experienced a serious safety error. Typically, groups of clinician examine an event that caused patient harm to identify a cause for the event and to develop a plan to prevent similar harm to other patients. In performing such analyses, the teams recognize the need to go deeper into analyzing a safety event than simply describing "surface" reasons that they occurred.

For example, if a wrong-site surgery has occurred, it is not enough to say the cause was that the operating room (OR) team did not complete the appropriate surgical checklist. The analysis needs to answer the "root" reason it wasn't completed: For example: Was there a lack of education (team members did not know they should complete the checklist), a lack of accountability (no team member or members felt responsible for ensuring the checklist was done or done correctly), or a culture of fear in the OR (team members knew the list should be completed but feared the anger of another team member who would object to it) that prevented this important safety check from being done?

Publication Date: Thursday, December 01, 2011

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