Listen to yourself talk! Part 1

Although customer service is often given lip service in healthcare settings, long-term care (LTC) has shown more interest in resident and family satisfaction of late. LTC organizations are realizing that customer satisfaction has an impact on a number of operational areas. For example, unsatisfied customers are eight times more likely than satisfied customers to tell others about their experiences.1 Families are six times more likely to contact a lawyer because of rude or indifferent behavior than because of an underlying care problem.2 Referral sources hesitate to refer patients to facilities when they receive reports or complaints from families about poor service. Finally, employees want to be a part of a winning team, and a lack of skills in dealing with difficult families and residents leads direct-ly to employee turnover.

The release of the first-ever national report about customer satisfaction, “2005 National Survey of Resident and Family Satisfaction in Nursing Facili-ties,” published by My InnerView, has created an even greater interest in customer satisfaction. Although 83% of the respondents rated their satisfaction as “excellent” or “good,” only 30% rated satisfaction as excellent.3 A few individual items were rated even lower, with the excellent rating only at 17% for dining experience, 18% for adequate staff, and 20% for laundry. The bottom line is that while nursing facilities do a good job, they have a lot of opportunity for improvement.

So where do you stand on this issue—do you pay lip service to customer service? Do you set your standard at “good” customer service, or are you truly interested in excellence? One way to find out is to listen to yourself talk. The sidebar (“Eight Expressions Reflecting on Customer Service,” p. 54) lists eight expressions that you may have used (or may have heard someone else use) in the “heat of battle.” What do these expressions reveal about your attitudes toward excellence in customer service? If you are a regional manager or regional consultant, when you walk through a nursing facility, can you sense just from listening whether this is a well-functioning facility? Have you spoken with the administrator or some of the staff and quickly formulated some judgments? Can you tell whether staff and management are focused on customers? Can you spot the warning flags that the center is not focusing on customers?

Part 1 of this article will focus on the first four of these telltale expressions and offer a perspective for dealing with them. Part 2 in a subsequent issue will deal with the remaining four.

1. “There are some families you will never be able to please.”This statement is a huge tip-off that you have divided your customers into two classes—those who are easy to please and therefore receive good service, and others who are more challenging and become second-class customers. Staff may believe that it is OK to treat these customers differently. They may avoid the challenging customers. In some instances, they may even have their favorite negative label for them—“complainers,” “whiners,” perhaps some terms that cannot be printed here. They rationalize this under the premise that they treat most of the other customers pretty well.

The reality is that this attitude lowers the standard of customer service. Staff will become complacent regarding good customer service and provide it only when it is easy or convenient to do so. Remember, customers—even in a nursing facility—do talk with each other and do observe interaction with other customers. And even mildly upset customers become more angry as they are responded to inappropriately.

This whole chain of events can be headed off with this standard for excellence in customer service: Display a positive attitude toward all customers. A few suggestions: First, realize that some of the very customers that you label as “difficult to please” are customers that you have created. When there is a service failure, you have the opportunity to create a more loyal customer or a more angry customer by how you respond. Second, when you are discussing customers with staff, picture the customer being in the same room and hearing everything (the “fly on the wall” concept). Would that cause you to be more objective in your remarks, to present both sides of the story, and to be more mission-oriented? Third, banish the use of all labels other than “customer.” Even innocent sounding labels, such as “hypervigilant” or “white knight,” quickly become code words for difficult customers, have negative connotations, and lead to inappropriate responses by staff.

2.“I don’t know if our aides have the knowledge or skills to handle a difficult family.”That may be very true. However, what have you done this week to change this? What have you done this month? This quarter? It is, after all, your responsibility as a manager to ensure that staff has the knowledge and skills to perform the job. Do you have a structured program that prepares your frontline staff to handle customer situations? If you do not, you are putting your staff at a disadvantage, and your customers are experiencing something less than excellent customer service.

So, in what areas should you have standards? I would suggest that a good starting point is to have standards for how customers are greeted and addressed, for how concerns and complaints are handled, and for how basic services, such as answering call lights or serving meals, should be delivered. Try replacing the above phrase with the following: Have clear standards for excellence in customer service.

Of course, the starting point for implementing this standard is supervisors. They need to understand, practice, and reinforce these standards daily. To get their “ownership,” you might consider allowing supervisors to have input in developing these standards.

3.“We do look at customer satisfaction results—once a year.”Really! That often! Can you think of any other area of performance in the facility where results are tracked and reviewed once a year? Receivables? Occupancy? Labor hours? Food costs?

Of course not. That is because, to truly achieve superior performance, you need frequent metrics to determine if you are on track. So, replace this phrase with another standard for excellence in customer service: Check satisfaction often.

This has been stated more eloquently by Johnson and Gustafsson, prominent researchers in customer satisfaction: “Measuring quality, customer satisfaction, and loyalty should be an ongoing, repetitive process…. Remember that there is a difference between customer measures and surveys as a basis of a measurement and management system, and more informal surveys or methods designed to take a quick pulse or to identify problems methods as they occur. The latter methods typically focus on the most recent episode or transaction with a customer…. They may be a valuable source of information for service managers or front-line service personnel to catch and resolve certain classes of problems as they occur.”4

Some practical suggestions: Check on satisfaction of all new admissions. This survey should be done within the first few days, in person, with the resident. Check on satisfaction of all customers monthly on some dimension of service. Consider conducting brief surveys monthly, for example, on dining services, the room environment, or just general satisfaction. Keep the survey simple and collect verbatim comments.

“Many organizations concerned with improving customer and employee loyalty have developed a variety of increasingly lengthy survey forms to capture feedback…. One key to effective communication is to keep it simple…pare the surveys down to four or five essential questions and leave plenty of space at the bottom for additional comments.”5

Who will administer all these surveys? “You can’t do this yourself. You don’t have time! So involve staff…. Set up a two-week period during which staff gather information from customers…. Give each staff member an assigned customer group…. Give each member copies of a customer contact form and ask them to use it as a guide to recording their answers when gathering information from customers.”6 By involving staff in this way, you also get the added advantage of having staff hear firsthand resident issues—and hear their compliments!

None of this is to diminish the value of annual or biannual, more extensive surveys that allow you to benchmark your progress. But you must have more frequent measures that provide you with real-time information on whether you are actually satisfying customers.

4.“We do a good job with customer satisfaction. Our average rating is above the midpoint on the scale we are using.”Mark Twain once said, “There are three kinds of lies: lies, damned lies, and statistics.” Averages can distort the true picture of your satisfaction levels and do not give managers the information they need to improve performance.

You are interested not in the average satisfaction of your customers, but in how many are satisfied. A much more meaningful statistic might be the percentage of new admissions who were satisfied with their first couple of days, or the percentage of residents who rate meals and the dining experience as “excellent.”

The type of scale you use is important. “The measurement challenge is to be able to distinguish among customers that are crowded together at the high end of the scale…. Unfortunately, yes-or-no questions give you no way to distinguish among customers that range from moderately satisfied to very satisfied. The sensitivity of the scale improves when you move to a 5-point scale. Research on quality and satisfaction scales suggests that using a 10-point scale is better still.”4

Also, “We recommend using 10-point scales, where 1 is poor and 10 is excellent, to evaluate performance across data collection methods.”4

Finally, strive for a “top box” response—for example, an “excellent” response, a 5 on a 5-point scale, or a 9 or 10 on a 10-point scale. If you do that, you will be demonstrating this standard for excellence in customer service: Raise the bar.

There are two reasons that researchers “focus on the ‘very satisfied’ families and staff. First, research has repeatedly shown that a mere three percent or so of families and staff register strong dissatisfaction with their long term care facilities, regardless of the response scale used. When responses are heavily clustered at the ‘satisfied’ and ‘very satisfied’ end of the scale…they pose problems for certain statistical analysis. Second, research has also confirmed that families and staff who say they are ‘satisfied’ are randomly distributed in all types of nursing facilities. This reflects the common tendency among respondents to check off the ‘satisfied’ box in a questionnaire rather than show displeasure. However, they will not admit they are ‘very satisfied.’ The merely ‘satisfied’ respondents do not help researchers to distinguish between mediocre and superior long term care facilities. The ‘satisfied’ category does not correlate with other quality-related outcomes. The ‘very satisfied’ respondents, however, turn out to be good predictors of quality issues in a long term care facility.”7

You can see from these examples how common expressions used by staff can reveal both problems and solutions with respect to customer satisfaction. Expressions number 5–8 will be reviewed in a subsequent issue.

Ronald E. Retzke, PhD, is President of Retzke & Associates, Inc., providing consulting and training in service recovery, excellence in customer service, and quality improvement.

For more information, phone (262) 786-1627 or visit To send your comments to the author and editors, e-mail


  1. Gitomer J. Customer satisfaction is worthless: Customer loyalty is priceless. Austin:Bard Press, 1998:136.
  2. Hickson GB, Pichert JW, Federspiel CF, Wright Clayton E. Development of an early identification and response model of malpractice prevention. Law and Contemporary Problems 1997; 60 (1): 9.
  3. My InnerView report, June, 2006. Available at My InnerView, 2620 Stewart Avenue, Wausau, Wisconsin 54401.
  4. Johnson M, Gustafsson A. Improving Customer Satisfaction, Loyalty, and Profit. San Francisco:Wiley & Sons, 2000:42-3.
  5. Reichheld F. Loyalty Rules. Boston:Harvard Business School Press, 2001:161.
  6. Leebov W, Scott G, Olson L. Achieving Impressive Customer Service: 7 Strategies for the Health Care Manager. Chicago:Josey Bass, 1998:55.
  7. Tellis-Nayak V. Customer Satisfaction in Long Term Care: A Guide to Assessing Quality. Washington, DC:2003:7.

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