Service Excellence in Health Care

Assessing and reporting on the quality of health care has become a fact of life.^{1 - 7} Quality outcomes are now compared among institutions and reported in both the consumer press and peer-reviewed literature to the delight of some and the consternation of others.^{8 - 10} Into this debate on comparing quality of care among institutions and clinicians come some unsettling notions. Can clinicians effectively measure and compare not only quality of care but quality of service? What is the link between defined clinical outcomes and perception of the quality of service in delivering patient care? Can patients rate both the skill and service of physicians and nurses? What is more important—outcome or satisfaction? Despite a rapidly expanding body of research on service quality in health care, these intriguing questions are still largely unanswered.

Just as dedicated researchers have documented that quality improvement techniques can be applied to health care,^{11 - 12} researchers are also examining whether the principles of effective customer service can be applied to health care.^{13 - 16} Several aspects are clear. First, patients want reports on both the quality of clinical care and the quality of service in health care.^{17 - 18} Second, patients' perceptions of service satisfaction have a clear impact on their perception of quality of care, as shown in studies of family practice, internal medicine, surgery, and emergency medicine.^{19 - 22} Third, while the technical competence of health care is well established and, at times, breathtaking in its accomplishments, it is no longer enough to ensure that patients are satisfied,²³ regardless of whether the missing element is called customer service, patient satisfaction, caring competence, beneficence,²⁴ or good old-fashioned bedside manner. Taken together, these 3 facts point to the need for combining technical expertise with service excellence in health care to improve clinical care, as well as the patient's perception of that care.

While it is clear that clinicians would like to improve patient satisfaction, a clearly defined means of doing so—consistently, effectively, efficiently, and, presumably, while maintaining quality of clinical care—is lacking. Nonetheless, many health care managers are in effect holding their staff accountable for a skill—customer service excellence—for which the majority have never been formally trained. As this increased accountability for patient satisfaction becomes more prevalent, 1 of the most difficult dilemmas is developing a concise and meaningful answer to the question virtually all physicians face: Are individuals seeking care patients or are they customers? For most physicians and health care workers, the answer to this question is straightforward—individuals seeking care are patients, not customers. Education, training, and experience (to say nothing of visceral reaction) have led clinicians to believe that they are patients, not customers. (Customers may refer to a diverse range of participants in the health care process, including patients, family members, payers, employers, and practitioners. However, for the purposes of this article, we restrict the use of the term to those who are the direct recipients of the health care provided—those who in the past were generically known as patients.)

To stimulate discussion regarding this question, we have used an exercise that helps health care professionals realize that they have their own inherent and intuitive definitions of customers and patients, even if those definitions have not been clearly articulated. Imagine a gauge, with a needle pointing toward either the word "patient" or toward the word "customer," depending solely on the reaction of the health care professional to certain clinical scenarios. After reading or hearing each clinical scenario, the respondents are asked whether they would classify that person as a patient or customer.

SCENARIO 1: A 55-year-old woman presents to the physician's office with intermittent chest pain of 2 weeks' duration. The current episode began that morning, necessitating an urgent appointment. The patient rates her chest pain as 9 out of 10, and findings on her electrocardiogram clearly show an acute anterior myocardial infarction. Is this a patient or a customer?

SCENARIO 2: A 3-year-old-boy is brought to the physician's office by his parents. The child had been seen the previous day by another physician, who diagnosed left otitis media and prescribed antibiotic therapy and fever control measures. The parents state that they "can't get the fever down," although the boy's temperature is 37.5°C. Is this a patient or a customer?

SCENARIO 3: This scenario is the same as Scenario 2 with 1 exception—now the child is the respondent's child. Is this a patient or a customer?

Among the thousands of health care professionals who responded, who have diverse backgrounds, and who live in broad geographic locations, the results are strikingly consistent. The woman in scenario 1 is universally rated as a patient, whereas the child in scenario 2 is rated as a customer (with the parents invariably being identified as the primary customer). Scenario 3 invariably causes health care professionals to question whether they would classify their own child as a patient or a customer.

When health care professionals are asked why they rate the woman in the first scenario as a patient and why they rate the boy in the second as a customer, the results are also similar. As summarized in Table 1, patients are more acutely ill, are quite sick, have little or no choice in where they seek their health care, and are largely dependent on the health care practitioner to deliver technical expertise in a time-dependent fashion. In primarily patient relationships, the health care professional is the primary locus of power and has control during the encounter. Customers are less acutely ill or injured, have substantial choice, are more independent, and have substantially more power and control over the health care encounter than do patients. The needs of customers are more service dependent. Health care professionals, without exception, also have noted that they have a high degree of clarity in knowing how to take care of patients, who primarily require technical expertise to care for their illnesses or injuries. In contradistinction, most health care professionals are far less clear about how to approach the customer, largely because of the lack of specific and detailed training in addressing such needs and expectations. This clarity in caring for patients and confusion in caring for customers is paradoxical in that research^{14 - 17} strongly suggests that service needs of patients are surprisingly uniform, spanning cultural, economic, and geographic boundaries, as well as the various levels of illness severity. Knowing the universal service needs of patients and being trained in providing for those necessities is precisely the type of information health care professionals need, especially the specific dimensions delineated by Cleary and Edgman-Levitan^{16 ,18} : individualizing care, coordinating care, improving communication, enhancing physical comforts, providing support to patients, giving patients choices, and ensuring smooth transitions in care. What is less clear is precisely how to apply these dimensions at the bedside.

Nonetheless, based on our experience with the above exercise, we believe strongly that health care professionals, even without extensive experience or specific customer service training, can and do make such patient/customer diagnoses in the daily course of delivering health care. We routinely assess patients and make an internal, entirely nonscientific judgment of whether they are primarily patients or primarily customers, usually according to a simple rule: The more horizontal they are, the more they are a patient. The more vertical they are, the more they are a customer.

The point is simple, direct, and obvious but has not been stated widely enough to be put into practical use at the bedside: just as all patients share a clinical diagnosis requiring technical expertise, they also have a customer service diagnosis requiring caring competence, compassion, and service excellence skills. To treat one aspect while ignoring or neglecting the other understandably results either in poor clinical outcomes or less than optimal patient satisfaction. This is not a new concept but simply an understated and neglected one. As the patients' clinical status improves because of appropriate use of technical skills and as patients move from the horizontal to the vertical position, aspects of customer service excellence assume more importance. Just as careful study and analysis have clarified that quality improvement tools can be used in health care, careful scrutiny must now be given to the best way to apply service excellence skills in caring for patients/customers. Clinicians must answer whether those they serve are patients or customers in part by using a skill they already empirically apply in the care of their patients as they make customer service as well as clinical diagnoses.

Returning to the scenarios in the exercise, is the woman with the myocardial infarction only a patient? Are the boy and his parents only customers? To answer those questions, another exercise is needed. Imagine performing a "patient-customer autopsy" on any given person at any given time. What would be the results if it were possible to dissect out what percentage is patient and what percentage is customer? Although most physicians tend to think of the woman with the myocardial infarction as a 100% patient, more careful scrutiny and thought would indicate that there is a part of her, however small, that is also customer. In addition, such 100% patients also have friends and family members, who certainly have customer service needs that must be met at the same time as the delivery of the technical expertise necessary for optimal clinical outcome. Similarly, the child with the fever and his parents are never quite 100% customers either. The degree to which they are considered patients or customers is an indirect reflection of how horizontal vs how vertical they are. Elements of both patient and customer exist in all clinical encounters. Just as the clinical status of patients changes through the course of their care, so too do their customer service needs. In addition to applying technical skills to treat the clinical diagnosis, physicians must be aware of ways to expand and enhance service skills to treat the customer service diagnosis.

Thus, the answer to the question "Are they patients or are they customers?" is that persons seeking care are always both, to varying degrees depending on factors that are intuitively known by the health care professionals, which center around issues of patient illness, level of choice, and dependency. Just as patients have clinical diagnoses, they also have customer service diagnoses—a set of hopes and expectations regarding their clinical care. Furthermore, the people clinicians serve have their own estimates of whether they are patients or customers. As the third scenario illustrates, it should not be surprising if the patients' estimation of whether they are patients or customers is not congruent with those of physicians. Clearly, in these cases, health care professionals must negotiate when differences in expectations exist between the clinician and the patient.

To take seriously the challenge of providing service excellence to patients, clinicians must begin by using their diagnostic and interpersonal skills to assess not only the clinical and technical diagnosis, but the customer service diagnosis as well. Only when that analysis occurs is it possible to think about which of the service skills identified in numerous industries can be applied in treating the customer service diagnosis. There is science in customer service, and those principles and techniques have been well described and identified.^{25 - 32} As clinicians seek to apply these principles to health care, they must adapt them to take advantage of the best aspects of both the art and the science of medicine in making clinical and customer service diagnoses. Just as the advent of continuous quality improvement in health care required learning a new language (as well as learning to use new tools and techniques), applying customer service principles to health care also requires an adaptive learning process with a new taxonomy, as well as tools and techniques such as dimensions of care,¹⁴ service transitions,²⁵ service recovery,²⁷ negotiation skills,²⁶ and moments of truth.³³ The good news is that the essential background of beneficence and the art of medicine can be combined with technical competence to ensure that the horizons of medicine are broadened. Accordingly, patients can be assured that clinicians are not only making the correct clinical decisions but that they are cognizant of the patient's personal needs, thus producing both customer satisfaction and employee satisfaction, and making the clinician's job easier.