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This month, John Guaspari shares his views about the uses and misuses of customer satisfaction measurements. Recently named one of the "New Quality Gurus" by Quality Digest magazine, Guaspari has been one of the business world’s leaders for the past decade on issues of customer value and how to use the customer’s voice to energize organizational change. With a background in aerospace engineering, he held a variety of engineering, marketing, sales, and customer service positions. Since 1986, he has helped clients from many industries "make the customer come alive" for their employees. He is a senior associate with Rath & Strong, a Lexington, MA, consulting firm.
Q. You’ve written about the problems of using satisfaction ratings as a quality improvement strategy.1 Will you elaborate on those?
A. There is nothing wrong with using customer satisfaction readings as one strategy. I like to think of satisfaction as the extent to which you meet the customers’ expectations — in this case, your patients’ expectations. That’s a good thing, and attention must be paid to it. The problem is that it tends to trip up organizations. This is true whether it’s in health care or manufacturing or retail or financial services. What trips up people is not a lack of information; satisfaction surveys will give you information. The problem is a lack of organizational energy and alignment to affect positive change with the information.
The reasons, I think, are several:
1. Measuring customer satisfaction is inherently a negative thing to do. That might sound odd, since satisfaction sounds positive. But, when you’re measuring customer satisfaction, what you’re really measuring is the absence of dissatisfaction. While you don’t want your patients dissatisfied, you want to go further. You want to create positive results.
2. Paradoxically, measuring customer satisfaction is a self-absorbed thing to do. You’re probably saying, "Wait a minute! We’re talking to patients, how is that self-absorbed?" I think it’s self-absorbed in this way: You are asking patients to focus on you. You are basically saying, "Of those things we did for you, how did we do?"
That’s important to ask, but recognize that it will only get you one category of information about how you did. It says nothing about what you could be doing. It says nothing about an opportunity that you might have overlooked. Also, organizations start to feel self-righteous in saying, "We’ve taken care of our external focus stuff by doing a satisfaction survey," when, in fact, the measurement of satisfaction is just asking others to focus on you.
3. Satisfaction surveys define the box — in other words, standard elements of health service — when you really want people to get outside of the box. Satisfaction is a function of customer expectations. And those expectations are formed by what customers typically experience. While you need to know how you are doing on that stuff, satisfaction measures are silent on the question of, "What could we be doing that we are not doing today?"
Getting people focused on that is creative and very energizing. Organizations usually have difficulty getting people energized to effect change and there is an opportunity to address that by focusing on something bigger than satisfaction — something externally focused, outside the box. When people focus on creating value, they can step outside the box. Value is very much related to, but by no means synonymous with, satisfying customers.
Q. Could you give an example of how a health care facility could create value through an external focus on its patients?
A. I don’t claim to be an expert in the health care industry, but in a general way, I can speak to how an organization can find out what its customers value.
Step One is getting everybody in the organization single-mindedly focused on what is of value to customers. The way you find that out is not by simply asking customers, "How did we do?" but by institutionally asking customers a different sort of question like, "Tell me about you. I want to understand you. Let’s not talk about the processes you may have experienced at a health care facility. I want to understand who you are, your frame of mind when you are here. What’s important to you?" A smart way of putting this is, instead of asking, "How did we do?" ask, "How are you doing?" Then the focus is on the patient rather than the institution.
Second step is to get everybody in the organization focusing on customer or patient value. What tends to happen is that there are people who have a lot of day-to-day contact with the customer, or the patient. But oftentimes those who don’t have as much direct contact have a very big effect on what the experience is like for the patient.
The goal is to get everybody engaged with customers and maybe even directly involved in conversations with customers. So they get it not only as an intellectual proposition, but as a visceral proposition.
The third piece is to engage everybody in actively and explicitly finding ways to create more customer value. I know it sounds very simple to condense it into three steps, and implementation is more complicated than that, but I think that is where the focus should go.
Q. Typical questions on our patient satisfaction surveys often include, "How much time did you have to spend in the waiting room?" or "Were you satisfied with the way your provider answered your questions?" Are these surveys going to improve the quality of the health care experience?
A. Doing those kinds of surveys and gathering that information is a very good thing. And, if some kind of action is behind it, it could lead to improved quality results. Again, just as customer satisfaction is really the absence of dissatisfaction, I think quality is really the absence of defects.
Obviously, not screwing up is a good thing to do, but that ought not to be your goal. It’s not good enough for your patients. It’s also not good enough for the people of an organization. For example, when I go to work in the morning, I don’t want to say, "My goal for today is to just make sure I don’t mess up." I would rather work to a higher purpose than that. Similarly, I think that measuring time spent in a waiting room is very important, and you ought to reduce it, but it’s not the goal. It’s the foundation on which you then build value.
Q. Are there tools we should use to discover these value-building ideas from patients, or should we just sit down and talk with them?
A. A formal satisfaction survey is a very good thing to do, but we like to engage our clients in what we call "value conversations." We set up ways for large numbers of people from all departments in an organization to have direct contact with customers and engage them in conversation, so they get more than knowledge. They get a better feel for what’s important to customers. There is a rational complement to this; there is also an evocative complement to it.
Organizations often overlook the fact that everybody who works there has a lifetime of experience in being a customer, regardless of function, work experience, or age. They know that little things can have an enormously negative impact on them as customers. At the same time, they know exactly how some little simple thing that didn’t seem like that big a deal could leave them with an enormously positive effect.
When organizations understand how to come up with those little things, they can add enormous value for the patient. If you can get everybody in the organization, in every function, focusing and trying to understand the patient, you are more likely to find those types of things.
Q. Are you suggesting that gathering a group of health care consumers together with a group of hospital people and getting them to talk to each other could lead to added value for the patients?
A. Right! You can have meetings with patients or former patients. Or you can do it through focus groups of patients or former patients and their families. There may be ways to add value for the patient by addressing the needs of the family, for example. You can videotape the focus groups and have staff workshops around them. You’d be surprised at how people will come up with ideas to add value for patients.
Another excellent way for health care people to understand patients is to walk through the steps patients go through at their hospital or clinic; from the time they walk in the door, to the time they receive the bill for services. You could also sit down in a room and say, "Let’s imagine we are customers of this organization. What are all the steps we go through?" You visualize what the patient sees, who is there to help the patient.
The objective of all this is to help people make those connections of understanding how that patient feels. I’m not talking about feelings in the clinical sense, but rather in an emotional sense. I’ve seen people who work in an office but never have contact with customers. When they go through exercises like these, the understanding hits them between the eyes like a two-by-four! They recognize that some little thing they are doing causes enormous headaches for the customer.
Q. From your experience, what sort of impact would these kinds of exercises have on health care costs?
A. I like to use a simple definition of value that touches on that issue: What the customer "got," divided by what it cost the customer. "Got" means a product, plus a service, and a whole host of intangibles.
Cost is money, plus time, plus a long list of intangibles. By focusing on value, you are necessarily focusing on cost. That definition of value forces you to recognize that cost is in the equation. So you say, "We could give the customer or patient this service, but the commensurate costs would be enormous; so, it does not add value, in fact, it subtracts value." The ratio goes foul.
Where a lot of the benefit comes in, however, is in the intangibles. People too often leap to the hard product-related or direct service-related things that you give the customer and those do have a high-dollar cost attached to them.
If you focus on the intangibles, a lot of times you can do things which cost very little — in some cases, literally nothing. Like asking someone in an organization to behave in a slightly different way. There’s no additional cost to the organization, but there's significant benefit to the customers in terms of the overall experience they have.
I do not have a quick fix or easy answers to the dramatically changing economics of the health care industry. I am saying, though, that a focus on value necessarily keeps you thinking about costs.
Q. Have you seen examples of this in other industries where greater customer value can actually help contain costs?
A. Yes, let me give you an example from the hotel industry. A few months ago, I was meeting with clients in a hotel meeting room. I showed up in the meeting room at 8:00 and began to set up for the 8:30 meeting. At about 8:15, in walks the hotel function manager and asks me if everything was OK. I said everything looked fine.
He asked, "Do you know about our gold switch?" I didn’t, so he showed me what looked to be a light switch on the wall with a gold plate around it. He said, "If you need anything at any point during your meeting, just flip that switch. A light will go on in my office, and someone will come down and take care of your problem."
During the meeting, someone said they were going to run to the front desk to make copies. I told them to just flip that switch and see what happened. Thirty seconds later, somebody walked in, asked how they could help, and made the copies.
It was great to know that if something went wrong for me, I didn’t have to run around the building and chase somebody down. That confidence added value for me. It was great for the hotel, too, because the front desk did not have to find someone to solve my problem. They had one person manning the gold switch who could respond instantaneously.
1. Guaspari J. The hidden costs of customer satisfaction: Customer satisfaction alone can’t provide the kind of energy organizations need to sustain continuous improvement. Quality Digest 1998; 18(2):45-49.
• John Guaspari, Rath & Strong Management Consultants, Lexington, MA. Telephone: (781) 861-1700. E-mail: firstname.lastname@example.org.