Voice of the Customer (revisited)

Voice of the Customer (revisited)

I have written on the subject of customer/consumer/complainer voice many times (see for example: http://www.medicallaboratoryquality.com/2012/11/voc-voice-of-complainer.html ).  Asking for, and acting upon input from those that use your product or service is about as Deming as you can get.  Without that input there is no “S” for PDSA.  

Without feedback there is no Crosbian Quality until it is too late.  If you don’t ask, then the only way to discover that you are not meeting customers’ requirements is when they walk away.

So asking is not only important, it is critical, provided that you do it in a way that invites the responses that you want and need (see: http://www.medicallaboratoryquality.com/2011/06/satisfaction.html ).

But for every “ointment”, there is always the probability of the “fly”.  (Said another way, for every silver lining, there is always the dark cloud).   To stretch this analogy sequence one more time, what do you do when you send out your party invitations and still nobody shows?  

 
My point is that writing the perfect survey doesn’t cut it when nobody responds.

So let’s go through the possibilities.

Personal error:  You created the survey but forgot to actually send it out.  Oops – dummy!

Technical error:  You tried to create the survey but copied the link to the survey incorrectly, so that people who tried to respond could not find the survey.  Oops again – dummy dummy!!

Tactical error:  You created the survey and sent it out correctly, and yet many did not receive it.  That actually can be more common than you think.  There are some (many?) employers that do not allow surveylinks  into their email system. 

Selection error:  You picked and focused on the wrong audience.  Folks who are one time or sparsely intermittent users are rarely sufficiently interested in giving an opinion, although that may be a really important group to try and nurture; what is it about what you are trying to do that elicits indifference.  And is there something that you can do to change their attitude and interest?

This is actually a long preamble for me to express my own personal frustration.  I work in a world with a lot of folks interested in Quality.  We have that in common.  I provide a service for which they or their employers pay for them to participate.  That should make many of these folks “motivated customers”.   I know they receive the invitation to participate and I know the link works, but if I get a 50 percent opening up the survey rate, that is an exceedingly rare event.  Indeed it is rare that I ever exceed 33 percent.

Frankly I don’t get it.  We promote the survey only and with the information on why it is important.  The survey takes less than two minutes to complete.  The vast majority of information can be addressed by choice buttons, so that they don’t have to write anything.  There are multiple ways that their anonymity is protected.   Any yet not only do they not respond,  many don’t even open the survey.

Being involved in Quality usually means being interested in expressed opinion – of theirs and others.  In my experience, Quality oriented folks are rarely shy about expressing their mind, and inviting others to do the same.  And yet many, (far too many in my opinion) are comfortable in bypassing an open invitation to be involved. 

But let me be really clear.  Of the folks that do participate, we are really pleased with their opinions.  Most (YAY!! ) and pleased with what we are doing, others maybe not so much (kind of yay).  While we can’t respond directly back to the critical or positive folks (the downside of anonymity) we can be collectively transparent by sharing the results, which we do.  

Sometimes I speculate about sending out a survey to discern the characteristics of survey responders versus survey non-responders, but that would seem to be a hopeless jump down the wrong rabbit hole.  

When there appears to be no solution, does that mean give up and move on?  

Not very likely!!!

When is a person like a car?

Here is a riddle for you.  When is a person like a car?  It is not a trick question and the answer is exactly what you think.  A person is never like a car.  

 A car doesn’t care how it is made.  The person making the car might be interested in things like keeping errors to a minimum, cost, efficiency, but the car doesn’t care.  It just rolls along the production line being prodded and bolted and sprayed and polished until it is done.  People do care how they are made; at least that is what modern investigation tells us through the magic of MRI and other cool instruments.  The fetus displays all sorts of signs of adverse reaction to noxious stimuli. 

Similarly when a car is being repaired, the car doesn’t care if the repair folks are inept and use poor procedures and cheap parts to put the thing back like it was.  The car doesn’t know or care about costs and efficiencies.  Again the owner cares at both ends of the spectrum, either when it costs too much or too little.  But for the car it is just another day.

It is kind of a silly way of trying to make a point, but there is a point.  People really care when they are the subject of repair.  Patient satisfaction makes all the difference between a happy hospital and a hospital mired down in civil suits and bad press.  Patient satisfaction differentiates between the choices of malpractice or no malpractice.  People care.  

While this is intuitively obvious, there is nothing better than documented study to make a statement go from “well duh” to “and that’s a fact”.  And that brings me to a recent article in ASQ’s Quality Management Journal: Cost-Quality Trade off in Healthcare; Does it Affect Patient Experience  (QMJ Vol 22, No 3/ 2015, ASQ) .

Basically the author (Sriram Venkataraman) was able to look at two sets of information, one being scores on patient satisfaction (aka “experiential quality”) as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), a formalized satisfaction survey.

The other set of data came from information on physician-to-patient ratios, nurse productive hours, outlier payments, weighted Diagnosis Related Group (DRG) and other information including patient mix, and setting (rural, urban, large urban) and number of staffed beds.

When the comparisons were made, across the board, hospitals that had the greatest cost efficiency had the poorest satisfaction, and the longer the person stayed in the hospital the poorer the satisfaction level.  

To go back to the beginning, while Lean and cost efficiency is effective in industry with particular application to Toyota (ergo the riddle about the person and the car) patients do not like institutions that Lean out (or chisel out) every nickel.

Healthcare has made a number of strides towards Quality.  Fewer pharmacy accidents happen now, as do fewer nosocomial infections, although to be accurate there are still lots of pharmacy accidents and infections.  There are probably a lot less wrong legs being cut off.  

It we use crude markers of success, cost efficiency has reduced the number of lives lost due to hospital care.   But it is at a cost.  Patients do not get much sense of well-being while being hospitalized patients. 

Previously in this blog I have commented on patient satisfaction.  Given the state of healthcare today, the greatest “killer of quality” is the association of an endless supply of new patients with no impetus to providing good care and no consequence to giving poor care.  [see: http://www.medicallaboratoryquality.com/2014/12/competition-and-quality-partner-dynamic.html ] We see this regularly in Canadian healthcare across the country.  What patients put up with is just astonishing.  Unclean facilities, indifferent staff, and facility management that is deeply deeply committed to cutting every nickel they can. 

There are lots of reasons for how we have reached this point, many out of them control of management.  The reality is that the global economy has gone through a pretty gruesome downturn that has not rectified itself in now 8 years.  Governments are strapped, and revenue in healthcare facilities has not kept pace with expenses, or indeed anywhere in the social safety net.  There are fewer staff and the ones that are there many are tired and frustrated.  They don’t want to be there anymore than the patients, except for the fact that they are all making a lot of money.  

As I see it (as does the author) cost efficiency creates as many problems as it solves.  In Canada, a litigious free zone, there is little expectation of ever returning to  better satisfaction.  But in the US, at some point the level of dissatisfaction will become a significant issue that needs addressing.  And that will not be done through the “affordable care act”.

In the next entry I will tell you what I think can make things better.

The Power of On-line Courses

Once again I am in the middle of my on-line teaching commitment for the UBC Certificate Course in Laboratory Quality Management, and once again, I am loving it.

When I graduated from medical school and residency, I enjoyed working as an Infectious Disease specialist because it created the opportunity for a 1-to-1 relationship with patients.  It was satisfying to provide service and care in a truly direct fashion.  

But as my career progressed and I became more engaged in the laboratory and infection control, I found that my opportunities for impact and decision influencing were on a wider level – groups of patients distributed over wards and institutions.  What I sacrificed in terms of satisfaction with direct patient contact I picked up with system influence.  

With proficiency testing, if the direct patient impact was even further away, the system influence was much broader and covered health authorities and provinces and countries, and I was addressing quality assessment, quality improvement and education all at the same time. And as time marched on the education component grew from critiques to newsletter articles, to international training.  And the level of satisfaction grew even larger. 

But with the Program Office and the Certificate Course, the interaction scale has a whole new dimension to the dynamic.  While there is another layer that separates the laboratorian from patients, and sense of connection is much greater because the amount of interaction with laboratorians is much more intense.  Often we are communicating on a daily basis about Quality and Education and Laboratory improvement with folks taking the course are from across Canada and around the world.  The intensity and intimacy combined with the level of system influence can almost seem overwhelming.  

Over the years it has become very rewarding to attend meetings in many places and have people come up to me and say, “You may not remember, but I participated in your course in 2008 (or whatever) and I want you to know that it opened up a whole new career path for me.  Thank you so much”.  In the first 2 months of this year, I have run into people in 3 meetings with this same story.  And then there are the people who have contacted me through Linked_in.

It is very satisfying to know that so many people are pleased they took the opportunity to learn about laboratory Quality through our course.  I almost feel like Mr. Chips, if you know who that was.  

Recently we have been approached to consider developing a companion course which would cover another whole set of Quality related concepts not covered in the first course.  It is an intriguing idea.  As the whole arena of medical laboratory Quality grows (Thank you Institute of Medicine and To Err is Human.  Thank you ISO 15189) the body of essential knowledge continues to expand.  This is not information that is addressed in medical residency, nor in health administration, nor in the traditional MBA.  Increasingly people want it and institutions need it.  

I don’t know if this is a career path for everybody.  But it is a great path for me.

Hearing from the consumer - and getting it WRONG

I received another electronic customer satisfaction survey yesterday.  Perhaps some of you received it as well.  It was from the International Organization for Standardization (ISO).  I suspect I received it because about four months ago (maybe 5!) I purchased a standard from their on-line book store.  The experienced reinforced much that I have come to know and understand about ISO.  

Their survey presented a perfect picture of what happens when polar opposites try to come together; the outcome was not pretty. 

 

ISO is a unique organization.  On the one side it is a formal international body governed by formal rules of protocol and diplomacy.  With regard to bringing countries to the table, they are excellent.  

While some may complain about their propensity to spend a lot of other people’s money by having meetings in very expensive locations (some think ISO stands for International Sightseeing Organization), I understand the pressures they are under to be seen to be geographically fair.  Personally I think the UN model of having one or two identified fixed locations would be significantly more effective, but then again I am not privy to the cost analyses that they must have undergone.  

When it comes to writing documents, ISO has to be sensitive to nuances of language and culture, and at the same time create documents that meet the intent of the committee and all the countries represented that created the intended standard.  This takes a true mastery of editorial skills and talents.

On the other side ISO is an organization that tries to generate revenue from the sale of their documents, and this requires a whole different set of skills and talents.  From what I have seen over the last 20 years, ISO is tragically inept on consumer interest and marketing.  And they never seem to get better.

The survey that they sent me was a perfect case-in-point.   It reminded me of a reference in the bible that refers to four sons, one wise, one wicked, one simple and one who does not know how to ask a question. ISO has a lot in common with that last son.  

 It was clear that the people that wrote they survey had little concept about customer service or customer time.  They certainly have no idea about how to generate an effective customer satisfaction survey.  The questions were obtuse, difficult to mark, and there were far too many.  Worse upon worse, when one got bored with the questions, it was not allowed to pass by hyper-repetitive sections;  every question required an answer, or you could not move on.  

 So the outcome was inevitable; either they will get many people giving up and quitting in the middle, or they will get people who filled in the survey with gibberish.  Either way they lose.  

I wrote on this subject a couple years ago.  [see:  http://www.medicallaboratoryquality.com/2011/06/satisfaction.html ], and it comes up regularly.  I used to think that organizations that send out waste-of-time surveys were just old and clunky.  I no longer think that is the case.  

I suspect these are arrogant behemoths that are so involved in their own value and importance, they are oblivious they waste consumer time and value.  Sad commentary about an organization that hosts COPOLCO, ISO’s Committee on Consumer Policy which it says is responsible for promoting consumer interests in standardization.    From where I am sitting, there is little evidence that ISO remotely cares about their consumers.  And that is a real shame.

In recent experience I can say I get many surveys from companies that have cottoned-on to the better approach; the send out succinct surveys without mandatory answers.  These are companies that understand the things that ISO writes about, continual improvement, quality management, and consumer interest.

With regret this is that is NOT what is happening with ISO itself.  The word dinosaur comes to mind