2.5 hours

Relative to customer service, why is it suggested that we “underpromise” and “overdeliver”?

Chapter 2

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It is not the employer who pays the wages. Employers only handle the money. It is the customer who pays the wages.

—Henry Ford

CHAPTER OBJECTIVES

· Develop an understanding of what the various customers served by the healthcare organization and its employees need from their relationship with healthcare provider organizations.

· Briefly describe the impact of managed care on the delivery of services to the customers of the organization.

· Identify the essential elements of customer service.

· Address techniques that can be applied in improving the personnel systems that are so important in providing and sustaining superior customer service.

· Identify the elements of an effective customer satisfaction system.

KEY TERMS

Managed Care: An approach to the delivery of care intended to address the problems of providing reasonable access to quality care at affordable cost, including economic incentives for providers and patients. The most common form is the health maintenance organization (HMO), made possible by the Health Maintenance Organization Act of 1973.

Customers, External: External customers are those from outside of the organization with whom you may have working contact, including patients or clients, families, visitors, vendors, contractors, and others.

Customers, Internal: Internal customers are all those persons internal to the organization with whom you may have working contact, foremost among them your employees, employees of other departments, physicians and other professionals,

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WHO ARE OUR CUSTOMERS AND WHAT DO THEY WANT?

The foregoing question is fundamental to the operation of any activity that provides goods or services. And “customers” include more than just those who purchase the goods or services. Any activity in any business has both external and internal customers. Customers external to healthcare organizations include patients, patients’ families and visitors, referring physicians, doctors’ offices, blood donors, and third-party payers. Internal customers include nurses, staff physicians and other professionals, students, trainees, employees, departments, and committees.

There is a distinct difference between a person’s wants and that individual’s genuine needs. As the widow in the retirement home said, “I need a husband; I want Tom Selleck.” Patients are ordinarily aware of their wants. By and large they want quiet, clean rooms with all the conveniences of a first-rate hotel. They want tasty food served hot and on time. They want painless procedures and no waiting on gurneys or in ready rooms. They want courteous, attentive, skillful, and professional-looking staff. Most of all, they want to leave the institution alive and feeling better than when they arrived. On the other hand, few patients are completely aware of their needs for diagnostic tests or therapeutic modalities.

Physicians are not always cognizant of what they should order for their patients until they learn about some new diagnostic or therapeutic procedure. Then they demand it. They invariably want fast and courteous service and all the latest technology.

Insightful care providers take steps to determine what their customers must have (their needs), what they want, and what they do not want. To stimulate or modify the needs and wants of their customers, healthcare providers make their customers aware of new services or products as they become available. What they often forget to do is find out what new services or products their external customers want or need; in others words, some providers readily advise customers of what they are able to offer but fail to ask those customers what they would really like to have available.

In this twenty-first century the importance of customer service is continually increasing. At one time patients and even physicians had very few choices as far as points of care delivery were concerned; the acute care hospital was essentially the center of the healthcare system. Now, however, with organizational fragmentation resulting in a wide range of independent and often free-standing entities and control of resources largely in the hands of primary physicians, there are choices. And the

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INFLUENCE OF MANAGED CARE

The shift to managed care has had considerable impact on customer service. In terms of their effects on customers, managed care organizations—such as health maintenance organizations and preferred provider organizations—have placed certain restrictions on access to care. Government and insurers have forced providers to find ways of operating on less money than they might have received in the absence of managed care. Provider organizations have had to adjust to the financial limitations imposed on them. As a result the healthcare industry has experienced numerous mergers and affiliations and other forms of restructuring, making it necessary to tighten staffing overall at precisely the same time managed care is forcing an increase in customer service communication with an increasing number of internal and external customers.

Under managed care, for the first time in the history of American health care, significant restrictions have been placed on the use of healthcare services. Customers have been introduced to the use of the primary care physician as the “gatekeeper” to control access to specialists and other services. Under the gatekeeper concept, visits to specialists and certain others are covered only if the patient is referred by his or her primary care physician. Before the advent of managed care one could safely say that the acute care hospital was the center of the healthcare system. Now, however, in the role of gatekeeper it is the primary care physician who functions as the practical center of the healthcare system.

As managed care continues to mature and individuals gain more experience in dealing with it, enrollees are becoming more sophisticated in their knowledge of what is promised and what is delivered. Many persons are increasingly critical of how they are handled, especially concerning real and perceived barriers to their access to medical specialists and expensive procedures. Customer inquiries and complaints are on average becoming more complex and articulate and thus more difficult to address.

Although all agencies claim that quality care and patient satisfaction remain important, the emphasis on cost control and limitation of services is unmistakable. Managed care has been directly or indirectly responsible for staff reductions and for the replacement of numerous highly trained personnel with employees who have been educated to a lesser level and thus are paid less.

The impact of managed care is not likely to diminish in the foreseeable future. Many people depend on managed care plans. During late 1998 and 1999, some 160

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THREE ESSENTIALS OF CUSTOMER SERVICE

The essentials of customer service in any activity in which employees deal directly with customers are systems, strategies, and employees.

Systems

Systems include policies, protocols, procedures, arrangement and accessibility of the physical facilities, staffing, operations, workflow, and performance monitoring. Policy statements and procedure manuals provide behavior guidelines, rules, and regulations. For effective and customer-friendly policies, several things must be done:

1. Eliminate policies that adversely affect client satisfaction (for example, unnecessarily strict visiting hours).

2. Annually review all policies affecting customer service.

3. Establish a committee of supervisors and knowledgeable employees to address policy matters.

4. Introduce new policies designed to improve client service (for example, a special parking area for blood donors, more convenient locations and times for specimen collections).

For each new service that is introduced, consider a policy specific to that service.

Discussions elsewhere in this text address policies relating to personnel selection, orientation and training, reward systems, communication, empowering people, and building teams.

Strategies

Strategy in customer service consists of developing a customer-oriented culture. A customer-oriented culture is achieved when every employee understands that good service is expected, that exceptional service is rewarded, and that unsatisfactory service is not tolerated. Such strategy is embodied in statements of vision, values,

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Customer feedback is essential to strategy. We obtain feedback from a number of sources, including complaints, suggestions, incident reports, surveys, interdepartmental meetings, cross-functional work groups, task forces, and focus groups.

Employees

We can never forget our internal customers. Employees in all capacities are our best customers in that we must satisfy them before we can please other customers. A well-satisfied employee is one who is capable of extending the best in customer service to others. Concerning employee satisfaction, the principal personnel responsibilities of supervisors are to:

1. Determine and respond to the legitimate needs and wants of their employees.

2. Field the best possible team of employees.

3. Empower employees to solve problems (can each of your employees say “I rarely need anyone else to help me handle customer problems or questions”?).

4. Teach by example.

5. Insist on excellent customer service and constantly monitor the delivery of this service.

TECHNIQUES FOR IMPROVING PERSONNEL

SYSTEMS

Position Descriptions

In the summary statement of every position description the word “customer” should appear, with an indication of how the customer is to be regarded. (For example, “The goal of this position is to meet or exceed customers’ expectations and needs. Our external and internal customers include ….”)

Modify performance standards to include items addressing quality and customer service. Here are some examples:

· Exercises discretion with patient information

· Accepts night and weekend assignments willingly

· Displays tact in personal interactions with customers and staff

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Recruiting Process

Your goal should be to hire employees who are competent, caring, and resistant to turnover. Assist in the recruiting process by providing the employment section of your human resources department with concise, up-to-date position descriptions. Be sure the attractive aspects of each job are prominent in those descriptions, but be honest concerning job duties that may not appear quite so attractive. Help the recruiters by recommending the most effective means for identifying potential job candidates. Answer inquiries about jobs enthusiastically, and interview candidates promptly.

Selection Process

Hire for attitude, train for skill.

The ability to sell jobs to candidates is important. The stronger the candidates appear to be, the more likely it is that other organizations will be trying to hire them. You can learn a great deal about a candidate’s attitude toward customer service by asking the following questions: What does superior service mean to you? What gives you the strongest feeling of satisfaction about your workday? Provide an example of how you made an extra effort to serve a client.

Orientation and Training System

Make certain new employees know who their external and internal customers are. Orient them toward exceptional customer service. Infuse them with the latest ideas in quality improvement. Emphasize the importance of a “can do” attitude and how this can affect performance ratings. Review workflow and carefully address each point at which the providers and recipients of service come into direct contact. Alert new employees to questions that customers frequently ask, and let them know where the answers can be found. Describe what you regard as proper telephone and electronic communication etiquette. Introduce them to the department’s major customers.

Performance Review and Reward Systems

Refocus performance objectives and performance appraisals to strongly address customer satisfaction. Discuss customer service when reviewing past performance and when formulating objectives for future activities. Encourage employees to set objectives such as attending seminars on communication skills or customer service,

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Tie your recognition and reward strategy to customer service. Unfortunately, the healthcare personnel who have the most client contact are among the lowest paid, receive the least training, and have the least opportunity for promotion, yet these are the employees who need to know of the vital importance of outstanding customer service and who need to receive strong positive feedback for their efforts in providing good service.

In-service Educational Programs

In-service education topics for all employees should include customer identification, recognition of customer expectations, customer problem solving, presenting new services, and communication skills, telephone courtesy in particular. Topics for employees responsible for contact with customers should also include empathic interactions, listening skills, dealing with complaints, assertiveness, and how to cope with angry people.

Personnel Retention

Turnover of personnel presents a major impediment to customer service. Unfortunately, the employees who provide the most hands-on service experience the highest turnover rates. (These topics are addressed in greater detail elsewhere in this text.)

DESIGNING A CUSTOMER SATISFACTION SYSTEM

Principles of effective customer service for supervisor and employees include the following:

· Always treat customers as you would like to be treated; this should be a cardinal rule.

· Anticipate your customers’ needs and wants.

· Hire employees who have a caring attitude, and retrain, reassign, or remove those who do not.

· Include customer satisfaction in your orientation and training programs.

· Make yourself a model of good customer service.

· Make customer satisfaction a condition of satisfactory performance.

· Monitor the behavior of your service providers, and coach those who demonstrate any deficiencies.

· Obtain frequent feedback from internal and external customers.

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· Under-promise and over-deliver; whenever possible giving customers more than they expect.

· Perform every task the right way the first time.

· Recognize and reward those who make special efforts to please customers.

· Give your employees the authority to resolve customer complaints.

Address Complaints

Patients are most likely to complain about noise, food, their rooms, waiting, and lack of courtesy. Customers are displeased when:

· They do not receive what is expected or promised.

· They have to wait for what they consider excessive amounts of time.

· Someone who represents the organization is rude, patronizing, or indifferent.

· They believe they are getting the brush-off or the runaround.

· Someone expresses a “We can’t do it” attitude or hits them with the rule book (for example, “It’s our policy”).

Always regard complaints as suggestions for improving service. Some complaints are not legitimate, but a great many are. Legitimate or otherwise, an employee’s initial response to any complaint should be careful listening. Complaints are the least costly source of customer feedback. Invite additional comments and ask for specific suggestions for improvement. Encourage your staff to report complaints and make suggestions for eliminating them, and record these suggestions. Express your appreciation of these suggestions at performance reviews as well as at the time they are offered.

Chapter 29

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Make sure the jobs you give your people are whole and important and that you really give them the jobs. Ask them not to report unless they’re in trouble. Grit your teeth and don’t ask them how it’s going.

Hopscotch Delegation: This occurs when your manager bypasses you and gives an assignment directly to your subordinate without including you in the process; this is a dangerous practice that tends to undercut your authority.

Empowerment: Empowerment might be best described as total, proper delegation, giving people the authority to do what they are capable of handling and encouraging them to make judgments, form conclusions, reach decisions, and then act.

ASSIGNING VERSUS DELEGATING

Assigning is telling a person what to do, how to do it, and when the task must be completed. The tasks are usually of a nonsupervisory nature and for the most part are found in the position descriptions for particular jobs. There may or may not be an assignment of authority. Delegation, on the other hand, is the transfer of authority, responsibility, and accountability. The tasks are activities that the delegator was previously doing or had expected to do should they arise. Delegation is usually negotiable or optional and requires a commitment by the delegate; concerning assignment, the employee need only do what he or she is told to do, usually without question.

WHY SOME SUPERVISORS ARE RELUCTANT TO

DELEGATE

There are a number of reasons why some supervisors hesitate to delegate or avoid doing so altogether:

· They are workaholics or perfectionists.

· They are insecure because they are afraid that (1) the individual will fail,

(2) the employee will do it better than the supervisor could do it, or (3) they will be accused of dumping.

· They do not like to turn over tasks they enjoy doing.

· They do not believe their employees are ready or willing.

· They have had unpleasant experiences with delegation.

· They do not know how to delegate properly and effectively.

Supervisors who are reluctant to delegate make statements such as:

• “I don’t have the time.”

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· “If you want things done right, you’ve got to do them yourself.”

· “Why delegate it? I can do it faster and better.”

· “When I try to delegate, the employees say that it’s not in their position descriptions, or they ask what’s in it for them.”

WILLINGNESS OF EMPLOYEES TO ACCEPT

DELEGATED ACTIVITIES

The willingness of employees to accept delegated tasks is usually determined by whether or not:

· They believe themselves to be qualified.

· Their previous efforts have succeeded.

· They are concerned about what their teammates may say or think.

· They believe they have sufficient time available.

· They like the delegated activity or see some reward in it.

· They believe they will have enough authority to get the job done.

· They believe the delegator will support them.

· They believe they are being manipulated or dumped on.

DUMPING

Delegation is a double-edged sword. It can be the key to increased productivity, better time management, and improved motivation, or it can be a wet blanket that squelches initiative and reduces morale. The latter outcome occurs usually because the supervisor has been “dumping” rather than delegating.

· Fail to see any personal advantage in carrying out the assignment

· Have not been told that occasionally they will be asked to do things not in their position descriptions

· See the delegator wasting time while they do all the work

If you enjoy good rapport with a subordinate and rarely take advantage of your authority, the subordinate will not mind some of the less pleasant or less challenging assignments.

When you assign a task to an employee and another employee asks, “How come you never ask me to do that?” what you have accomplished is most likely delegation. When an employee says “How come you always stick me with this?” you are most likely dumping.

HOW TO DELEGATE

Four Simple Ways to Pick What to Delegate

1. As you go about your daily routine, just before you tackle a task, ask yourself whether this is something that someone else in your group could do.

2. When you return from a vacation, list your duties that subordinates took care of while you were away. Some of these temporary assignments could become permanent.

3. At performance reviews, when you discuss future career plans for your associates, ask them whether they would like to take over any of your responsibilities.

4. Select tasks from those listed in your position description (see text that follows).

Delegating Using Your Position Description

· List 10 or more of your tasks, excluding any that cannot or should not be delegated (see list that follows).

· Select those that someone could assume now and those that a member of your group could learn to do.

· Prioritize each task according to how much time you would save by delegating the task, how significantly it would benefit or be acceptable to

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What May Not Be Delegated

· Accountability: Delegators remain accountable to higher authorities for delegated work; you can delegate the task but you remain accountable for the results.

· Powers other than task performance authority: Only formal power, or authority, can be delegated (see Exhibit 29–1 for distinctions among kinds of power).

· Activities forbidden by law, regulation, or policy (licensure, certification, special training, qualification, or education is required for some duties).

What Should Be Delegated Only Partially and Always with Caution

· Sensitive or high-leverage activities dealing with people:

· Interviewing, selecting, and orienting new employees (a delegate’s best role here is that of making recommendations)

· Approving new hires (again, it is best for the delegate to be limited to making recommendations to the supervisor)

· Coaching and counseling (a constructive use of senior employees who can also serve as mentors)

· Disciplining, evaluating employee performance, and resolving personal conflicts, complaints, or grievances (again, largely a recommending role)

Exhibit 29–1 Kinds of Power

· Authority: Delegated power. “You all report to me because the organization chart says so.”

· Competency: The power of expertise. “See Louise, she’s the only one who really knows this stuff.”

· Knowledge: The power of information. “Ask Joe; he’s on the committee and he has all the figures.”

· Physical: The power of brute force. “If you want to stay healthy, you’ll do as you’re told.”

· Connections: The power of who they know. “His mother is on the Board.”

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· Union: Power conferred by one’s peers. “Nora will get action; she’s the union rep.”

· Charisma: Persuasiveness. “He can talk you into anything.”

· Activities that involve too great a career risk for the supervisor or the delegate

· Activities perceived by the delegate as dumping

· Special administrative responsibilities of the supervisor, such as:

· Formulation of mission statements, goals, objectives, strategies, andplans

· Making, publicizing, explaining, and enforcing policies

· Presiding over important meetings

· Preparing or approving budgets and reviewing fiscal variances

· Tasks assigned by your superiors to be done by you personally

· Some functions that you find very pleasurable

Select the Delegates and Get Their Acceptance

Select delegates who have the necessary competence and display the willingness to take on the task. The most qualified person for a particular activity may not be the one who benefits from it most. A less experienced employee may try harder and do a better job in the long run.

Seek cooperation. Avoid petulant or grudging compliance. Consciously or unconsciously, delegates ask you or themselves, “What’s in this for me?” If their perception is negative, the delegation is in trouble. Be wary if you hear the following:

· “Is that an order?”

· “Do I have to?”

· “That’s not in my position description.”

· “Nobody told me I have to do all that.”

People are more willing to take risks if they know for certain what is involved. Perhaps in the past someone took a small step, and Pandora’s Box opened. Tell them exactly what they are getting into, and give them possible outs. Start by telling them:

• Why you decided on the change

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· Whether or not they have a choice

· What you expect

· What resources and authority are available to them

· What you are going to tell other members of the group if they are affected

· What, if any, modifications will be made to their current assignments

· The checkpoints and, when appropriate, a target date or timetable

When employees object because they do not have the time, agree to share some of the work or apportion some among others. At other times you can relieve them of other responsibilities. Usually, you can promise them that the delegation is reversible (for example, you will relieve them of the responsibility with no loss of their prestige). This is seldom necessary if you picked the right task, selected the right person, and prepared the delegate sufficiently.

How to Implement the Delegated Action

· Select the right task and the right person.

· If it represents a major change, get permission from your superiors.

· If you are operating in a team mode, discuss the change with your team.

· Provide essential training, resources, and authority.

· Agree on an action plan. Listen carefully to delegates’ ideas about how to get it done.

· Set up checkpoints. Checkpoints enable you to monitor progress and to give some pats on the back.

Monitor Progress

Be patient and persuasive, not demanding. Avoid statements such as “Don’t worry,” “You should have …” or “I wish you had ….” Help delegates when they get stuck.

Periodically stop by and ask how things are going. Avoid constantly looking over their shoulders or asking too many questions. Questions should reflect your interest in their approach rather than exhibit nervousness you may have about their ability to finish the job.

WHEN DELEGATION FALTERS

Avoid the temptation to abandon ship when there are problems. Allowing people to make some mistakes is the best way to encourage meaningful growth. Although a

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DELEGATION VARIATIONS

Horizontal Delegation

Truly skilled delegators can delegate to people over whom they have no authority. These individuals may be colleagues or volunteers. Horizontal delegation increases in importance as healthcare institutions feature more cross-functional activities and make greater use of volunteers. Success depends largely on factors such as:

· Persuasiveness

· Influence

· Interpersonal skills

· Rapport

· Degree of teamwork

· Past favors done for the other person

· Strength of one’s network

· Rewards and recognition for past cooperation

Reverse (Upward) Delegation

Hopscotch delegation occurs when your manager bypasses you and gives assignments directly to your subordinates. To correct this it helps to have good rapport with your superior. If you confront your superior when he or she is in a belligerent mood, you may get a response such as “Well, you’re never around when something has to be done.” If this shunting of authority rarely happens, it is probably best to ignore it. However, if you believe that a confrontation is necessary, take a positive approach by playing down the issue of authority. As you negotiate with your manager, focus on the advantages of your knowing what he or she wants done or of how your people get confused when they get conflicting orders from different managers.

If you cannot get action through your boss or if you want to avoid a confrontation, try acting through your staff. Instruct them to hold up action on nonurgent orders from other people until they have checked with you. Another tactic is to have your associates ask your boss in a polite way to please make the request directly to you because they are working on a priority item of yours.

If it continues unchecked, hopscotch delegation can be deadly. Every time your superior bypasses you and goes directly to your employees, your boss is violating the chain of command and is thereby undermining your supervisory authority.

EMPOWERMENT

Empowerment is one of the “in” terms to arise in management in recent decades, prominent in the terminology of the total quality management movement. Yet as often as it is used, there remains some confusion as to its real meaning and its actual appearance in practice. In fact, in any good dictionary or thesaurus, “empowerment” and “delegation” are offered as synonyms for each other. However, it seems that in practice empowerment has taken on the connotation of an activity that is somehow more appropriate and more complete than delegation.

Empowerment is a frequently misunderstood word. It decidedly does not mean that employees may do as they please without orders, monitoring, or control. In practice, empowerment means providing an environment and affording opportunities for employees to enhance their competencies and accept more responsibility. Call it, if you will, total delegation.

External empowerment is giving people the authority to do what they are capable of handling. It encourages people to make judgments, form conclusions, reach decisions, and then act. It liberates workers from rigid oversight and direction.

Internal empowerment, or self-empowerment, is what individuals generate

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Benefits of Empowerment

Empowerment enhances feelings of self-efficacy, a state of mind that causes people to believe they can cope effectively with situations and people. Empowerment reduces or eliminates feelings of helplessness. The more that people feel they are in control of their work and their lives, the greater their enthusiasm, optimism, self-confidence, and energy.

With empowered staffs, leaders can mobilize stronger forces when responding to crises and with less risk of chaos. The leaders can also set higher performance goals and standards.

Excellent healthcare service requires empowered care providers, especially when they interact directly with customers. Patients and other customers want providers who respond with confident empathy, not with calloused indifference, apathy, or plastic smiles.

Empiric Empowering Actions

Employees must know more than how to perform their daily tasks if they are to maximize their contributions. They feel more empowered when they learn about organizational financial matters and their role in providing excellent services.

Ten Steps that Empower

1. Know what each of your employees does and how well the tasks are done. Review position descriptions, performance standards, and previous performance appraisal reports.

2. Decide what additional authority they can handle right now. In their performance reports look for notes regarding competencies, experience, and training needs.

3. Ascertain what preparation each of your employees needs to achieve the competencies and mental toughness that empower them. Such preparation may involve training, coaching, psychological support, and incremental delegation.

4. Conceptualize a new supervisory role that reduces micromanaging and matches the level of supervision with the ability, maturity, and motivation of each employee.

5. Ensure that workers know the purpose (mission) of their jobs. Is this stated in their position descriptions and stressed during their orientation? If

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6. Delegate activities that involve decision making and problem solving.

7. Review your education and training program. Empowered organizations are learning institutions. Design a cross-training and job rotation program so that people become more flexible and more aware of customer problems and their solutions.

8. Make tasks more challenging. Assign complete rather than fragmented tasks. Assign progressively more difficult tasks, starting with ones that ensure success, an essential aspect of situational leadership.

9. Provide sufficient resources, time, and psychological support.

10. Emphasize commitment rather than conformity.

Potential Problems with Empowerment

It was previously noted that delegation involves risk. With pervasive empowerment, this risk is even greater. It is also greater than forming autonomous teams because you do not have teammates exerting a tempering effect on other members.

Some empowered employees do silly things; a few abuse their new authority. When employees are ill-prepared or when they believe you have not adequately rewarded them, they may rebel actively or passively.

Many workers are uncomfortable with more power, especially if they are passive or have victim mindsets. They prefer conformity and safety to entrepreneurship and risk. An often-heard comment from these folks is “I just want to do my work and go home.”

Employees may lack confidence in their leaders. Those who have been jerked around during a series of failed management initiatives are not likely to join in the celebration of still another program-du-jour. Instead, they hunker down and wait for it to pass as most of the previous ones have.

Some managers simply do not want to share power. They believe they worked hard to earn the power they have and are reluctant to give up any of it.