Healthcare, Customer Service, Real Life and a little help from Mel Gibson.

eriksoln, BSN, RN

Shortly after having a nice dinner with a couple friends I have not seen for some time, I found myself pondering the flaws in the assertion that healthcare must be "customer service" oriented. My friends, both of whom are, through no fault of their own, only marginally aware of the problems facing healthcare, both insist the push for better "customer service" in healthcare is long overdue. Well, unfortunately, I went off into a rant about all the reasons it does not and will continue to not work. I actually said a few things that surprised myself, at certain points it seemed as though I were talking and learning at the same time. Needless to say, both my friends have new and different gripes to pursue regarding healthcare now. I also believe it may be some time before we have dinner again.

Have you ever seen the movie "Lethal Weapon"? If not, I highly recommend it. There is a scene in that movie which, to this day, remains one of my all time favorite movie scenes. A cop, played by Mel Gibson, finds himself on a roof top trying to talk down a possible suicide jumper. What this jumper doesn't know is, the cop trying to help him has a lot of issues of his own going on, and he suffers from depression also. His depression though results in a suicidal approach to his police work. Well, the cop keeps talking to the man in a business suit on the ledge, all the while getting closer and closer to him. Finally, he is right beside him, still putting on the "nice cop" act and he cuffs him so he can't jump, and the nice guy act immediately goes away. He tells the guy "OK, shows over, its time to go, get off the ledge."

the man in the business suit isn't satisfied with this ending to his suicide jump show though. He begins to argue with the cop, even threatens to jump and take them both off the ledge. Finally, my all time favorite movie scene comes: the cop looks the jumper right in the eyes with a look of the Devil on his face and asks him:

"You wanna jump...............huh................Do you really wanna?"

Next thing you know, he takes the businessman by the shoulders and both are falling off the ledge towards the air bag beneath them. By the time its all over, the businessman can't wait to get away from him and is screaming for help to come undo the cuffs, "Help me, he's trying to kill me."

I believe the next time someone suggests to me that healthcare should be more like "customer service", they are going to have a similar experience with me. For me, its just a simple matter of "watch what you ask for, you might get it."

To start, I need to insert the disclaimer. When I say customer service has no place in healthcare, I am not advocating that nurses should be allowed to ignore pt. Needs, say whatever they want to family members or show up in jeans and a Metallica shirt for their shift. As with other healthcare professionals, nurses should be held to the highest standards of professionalism. Proper etiquette, treating patients with respect and dignity and a sense of duty to do what is right for patients has and should continue to be the basis of nursing's approach to people.

With that said, I will interject though that "customer service" and healthcare do not mix. They are like trying to mix water and oil. Why? Because the industries that are considered "customer service" (the food industries, retail etc...) use liberties to make the "customer service" model work for them, and said liberties would be unethical in the healthcare field.

1. Systematic customer service vs. Individualized customer service

Customer service industries, while taking (or at least advertising) a "the customer is always right" approach, don't always let their customers decide what is best or how to make the business function. Customer service industries are able to take either/or approach and decide for themselves which one is best for different situations. In plainer terms, customer service industries have the luxury of deciding when to put the business first and when to put the customer first.

Take the fast food industry for example. Think about any national fast food establishment. Now, compare how differently one restaurant, from the same chain, functions compared to the others in the surrounding area. Store a is open 24hrs/day, store b closes at 10pm. Why the difference? Because the powers that be who make decisions for the company have seen trends that say closing store b at night was going to save money, meanwhile keeping store a open all night had benefits.

The customer service industry makes many decisions like this, all the while keeping profits as high as possible. Customer satisfaction is weighed against the cost of keeping them satisfied, and decisions are made with the business's best interest in mind.

Take the above example a step farther. You are a customer of store b, and you don't get out of work until 10pm. You can't go to their drive through and get a late night dinner on you way home. Now, complain to the store manager. Chances are, you will get a very practiced and sincere (sarcasm) apology, but nothing will be done about it. Next, contact the administration who made the decision to have the store nearest you close instead of be open all night. You will get the same response and perhaps a $5 gift certificate. It's simple, staying open all night and getting your ten dollar sale doesn't justify paying a couple hundred dollars in employee wages. So, in the end you lose.

Give telling the cable man he can only fix your cable box at noon, no later and no earlier, a try. Chances are you will be listening to the radio for a very long time. Tell me what happens if you tell the local grocery store bagger that he must wear a tie or you don't want him bagging your food. Wait, I already know the answer.......you bagged your own food.

That is real life "customer service" at work.

This would not work for the healthcare industry though. It is a well known fact that a personalized approach to care is a major focus of the healthcare industry. If you get sick at 2am, the er at your local hospital will be open. The public and political backlash would be epic/historical if it weren't so. Can anyone imagine a hospital saying "we are going to accept patients only between the hours of 7am and 10pm, its just better for us and in turn will make things better for our patients." or, how about a home healthcare agency that does not take emergent calls during certain hours. With all the cutbacks being made in healthcare and everywhere else, it has not gotten to this point at least.

This is "patient care" at work.

2. Freedom to distinguish good customers from bad customers, and act accordingly

For this example, we will use a well known, national retail store, better know as a "convenience store". Cogo's is everywhere in the u.s., it survived the recession and will probably still be here when nothing but cockroaches and fungi roam the earth.

Walk into the Cogo's or similar local convenience store. A few things you will notice: the ever present and popular "no shirt, no shoes, no service" sign, signs around the cash register telling you this/that are not accepted behavior or these/those forms of payment are accepted, a security camera (sometimes multiple) making sure you are aware you are being watched and of course the also ever present and popular "shoplifting is illegal and we prosecute" sign can't be left out. The cashier working at the time may or may not say hello as you enter, depending on their mood.

Not the warmest welcome, to say the least. So, why do they continue to strive with such a poor first impression being their trademark? Because, all these things are a part of being allowed to decide who deserves service and who does not. They won't cater to anyone, especially if it is not good for business. Customers who are lewd, loud or disruptive are promptly removed from the premises, because they are bad for business. If a customer who does not like the prices of soda becomes verbally abusive or physical, they will be promptly removed and may be arrested.

This is real life "customer service" at work.

Lets return to the restaurant scene for a moment. Do you have a favorite place to eat at? Chances are, if you go there often enough and are a good tipper, you get a little better treatment than the unknown customers. Ever been to an unfamiliar restaurant while traveling. I'm willing to bet you saw a few locals getting better service than you. Do you have a friend (or, are you the one LOL) who does not tip or is demanding/abusive towards the staff? If you do (or are the one), then you certainly know what it means to get the minimal service, and, yes, your food may have been dropped on the floor a few times before you got it. Fact is, service industries do give that extra effort when a well liked big spender comes in the doors. It is a give/take relation to them, like it or not. Even the retail businesses do this with rewards for spending a lot and staff who are told "be extra nice to that one, he spends a ton of money here." anybody recall how the phone service giant, sprint, recently "fired" a large amount of customers and told them to find phone service elsewhere?

This is real life "customer service" at work.

The healthcare industry does not have this luxury. The mantra is "these people are sick, they are at the lowest point in their lives." I do believe that, to a degree, and believe any nurse who still has compassion does not take every patients actions personally. I think er nurses more than anyone can attest to the fact that we give people a lot of room for mistakes, and they still receive the care they need. Drug addicts attack hospital staff, family will insist you forget about everyone else and only tend to their loved one ("hey you, nurse, how long are you going to be doing CPR on that man, my mom wants water.") and verbal abuse is the norm. Despite conditions that would make the average citizen break down in tears, we strive to keep the patient first, regardless of whether they deserve it or not. We are obligated to do so. Does an er nurse telling you "sorry, can't cardiovert you until you put on shoes and a shirt" sound like something you want?

This is "patient care" at work.

3. The ability to keep business as the primary focus and turn away customers who can't/don't pay

No need to specify any specific industry for this, they all exemplify it.

Go to the local burger joint and when it is your turn to order, say to them "I don't have any money or credit cards, but you are "customer service" oriented and I am hungry. Soooooo..............hop too with making my burger and don't forget to hold the onions. After the laughter stops, you will be excused from the premises by the manager.

Don't pay your phone/cable/gas bill for a few months then call them and tell them "I'm going to give you very low ratings if you shut off my service" and see how effective your threats are. After the laughter stops, you will be isolated/bored/cold.

Fill your gas tank at the local gas station, but leave without paying. Trick is, you have to leave a card with your personal information behind so they can find you (OK, this is a stretch, but you get the point). After the laughter stops (for your stupidity and for your inability to pay), you will be fined.

This is real life "customer service" at work.

As healthcare providers, we are obligated to provide the best care we can, regardless of ability to pay. Yes, healthcare is a business just like all the other service industries. We do have to keep the doors open and staff paid somehow. The healthcare industry also gives vast amounts of charity care. Even without taking how uninsured patients use the er as their primary care service, this is still true. People are well within their right to sign up for "self pay" and receive the same care as anyone else. We know they will not be able to afford the bills, as do they. It's just a formal dance to get the patient admitted so treatment can be rendered. We take these people in, give them the same care as everyone else and don't look back. Often, people think its that way because it has to be. In truth, we wouldn't have it any other way. Everyone deserves life, regardless of ability to pay for insurance.

This is "patient care" at work.

What is the point of all this? My point is, you can not make "customer service" a part of healthcare without taking the good with the bad. To invite w/e aspects of "customer service" it is you are seeking into healthcare, you also invite "real life customer service" into the mix. This would be disastrous on many levels. Do you want a healthcare system that:

Closes at night, because its more profitable.

Tells the nurses to ignore the uninsured patient and focus on the paying patients (like the waitress).

Tells patients who are not as pleasant as they would like to "get lost" and not come back.

Only offers the services that are profitable for them at the time ("sorry, we don't have cardioversion equipment, it was too expensive to upkeep.")

So, I will say to the proponents of "customer service":

"Do you wanna jump?.........................huh................Do you really wanna?"

KY RN · Jul 3, 2011

This is an accurate assesment of today's healthcare system.

eriksoln, BSN, RN · Jul 3, 2011

This is an accurate assesment of today's healthcare system.

After I wrote this (and the one much like it in the General Forum), I realized I left out what could be considered the point of the whole article:

You don't want healthcare to be like "customer service" because it would be a step backwards, not forwards. We already do what the customer service model does and more.

I've actually talked to a few people about this article and gotten a few good viewpoints about it. Interesting how different departments and positions can see things so differently.

Persephone001 · Jul 5, 2011

I am not meaning to be offensive in any way, but I am just giving you my thoughts on my view point after finishing your article. I kind of have an idea of what you are trying to say, but I feel that the way the article is organized is confusing and does not make your point in the way that you want it to. I don't see where the Mel Gibson thing fits into the whole picture, unless you are trying to say that by making healthcare more customer service oriented that we are commiting suicide, and if that's what you were trying to say then a tie in at the end with you supporting that with the quote would make more sense. At the moment I can really only think of one thing ( I am sure there are others ) that has suffered from making the healthcare industry focus on customer service is the affect on nurses...nurses recieving more abuse from patients, nurses feeling over worked having to deal with getting patients water, more pillows, deal with the needs of their family all while trying to keep them healthy and alive, hospitals unable to keep enough nurses on staff, afford to pay decent salaries or afford to update medical equipement, etc. because they are broke due to so many patients who are not insured and cannot afford to pay for their hospital bill,etc. and all this leading to lower job satisfaction in nurses and leaving nurses wanting to get out of the field. I can see this leading more hospitals closing down and an increase in a lower grade of people going into nursing that are willing to put up with the lower pay, more work and all the other crap. Then you can tie in with some statistics to prove your point.

Please chime in if anyone has different opinions or ideas...

Wishinonastar, BSN · Jul 6, 2011

I think that economics created an excess of hospital beds and increased competition. This is why they turned to a customer service model. As the strong survive and the weak are eliminated by closure we will again have a better balance which will reduce the need for a customer service model. In time we may get to a point where there is rationing and even a waiting list for hospital beds. People will come to despise health care more so than they do now. Then they will long for the good old days when they were whisked away quickly to a hotel-like hospital room, given a fancy menu to call for room service, and treated as though they were our most important customer.

The truth is that we need to use customer service skills in any job that deals with the public. We need to be nice. There is nothing wrong with it. We need to be able to improve and to find out what patients like and don't like about us. We exist for them. But we also need to be able to set limits and not have to tolerate abuse. We need to have some rules and some control for the safety of everyone. It can't be a free for all kind of unstructured hotel type environment.

I think that nurses like to be able to have control. If we put too much into customer service we lose control and that can be a dangerous thing in an explosive environment such as a hospital. I don't think nurses should be allowed to treat people like Nurse Ratched- the ultimate control freak. But they can't be expected to drop everything and fluff your pillow right now or be written up for poor customer service. There needs to be an in between. Hospitals need to support the staff and not just accept that the customer is always right. Often he is not.

Be patient, the one thing that is certain in health care like everything else is change. Change will come, one way or another.

gjerstp · Jul 6, 2011

I believe the reason for the current focus on "customer service" in healthcare is because one of the elements of quality care is "customer" satisfaction - for "customer," read "patient." And QUALITY care is what we want to give our patients. Depending on where you work, you may have stories of how inconsiderately a nurse treated a patient, how long someone had to wait for a bedpan, how long someone else sat in his own excrement before someone cleaned him, etc. You prefer to work in a place that is known for its excellent, sensitive, competent care.

Each unit in a hospital (or any facility) has its own culture, which might be exhibited as a lack of individual kindness in treating the patients. This can stem from a caregiver's terribly busy day with altogether too little time to expend one minute on a smile and an extra personal comment. It can be that the unit is one where patients are perceived systemically as inconveniences requiring a lot of effort with little return, which may lead to cold, brusque treatment. It can be that an individual nurse has her own personal problems that affect the way she treats others.

I think many of us had forgotten how much a simple thing like a smile and a pleasant greeting can mean to someone who is fearful, ignorant, sick, weak etc. It was necessary to teach everyone in the hospital/facility to perform specific greeting and teaching activities in a consistent, reliable, effective way so that the whole institution is seen as "customer friendly." It's too bad it was necessary to mandate this, but it was. And if management on each unit is not committed to these processes, the people working on the unit will not adhere to them: "if no one really cares, why should I make the effort?" This is human nature at work.

Everyone hates change - that's human nature too. But when these simple actions, like asking if there's anything else you can do, or prompting patients to elicit needs they may not be aware of yet (Do you need the urinal? Can I get you some water? etc), are carried out consistently, the impression is of an institution whose workers all really are working to give the patients everything they need.

Customer service can never trump technical competency! It's assumed that each caregiver is as technically competent as possible. But the two are not mutually exclusive - you can give good care and friendly care at the same time.

Catch22Personified · Jul 7, 2011

Oh hi Madam ******* on Seroquel, you are refusing your medications once again? Do you want to stay here longer? Your insurance wont allow that.

I really hate how Medicaid patients feel ever so entitled even though they really aren't paying for the care.

billyboblewis · Jul 7, 2011

I read the article and the writers opinion. Apparently this writer has nothing important to do in her life. Spending time taking care of patients or helping the needy would be a start. A description of the service industry written by a lay person is not of much use to anyone.

Wishinonastar, BSN · Jul 7, 2011

Umm this is not a her and it is not a layperson. I think it is a reasonable analysis of the movement to make health care provision a customer service model. We serve you rather than we take care of you. We are a service that you are paying for, rather than are health care providers who you have entrusted with your care. There is a definite difference in the relationship with a customer service focus. It is more subservient. I prefer to be partners with patients- like a contract. I will help them with their health care. Customer service is more like you are paying me to do this for you. I exist only to serve you. It is a little creepy and reflects the influx of non-healthcare background MBAs into health care.

eriksoln, BSN, RN · Jul 7, 2011

Umm this is not a her and it is not a layperson. I think it is a reasonable analysis of the movement to make health care provision a customer service model. We serve you rather than we take care of you. We are a service that you are paying for, rather than are health care providers who you have entrusted with your care. There is a definite difference in the relationship with a customer service focus. It is more subservient. I prefer to be partners with patients- like a contract. I will help them with their health care. Customer service is more like you are paying me to do this for you. I exist only to serve you. It is a little creepy and reflects the influx of non-healthcare background MBAs into health care.

Yeah, I have a hard enough time being a male nurse, and then this.................

Wishinonastar, BSN · Jul 7, 2011

I still want you to come work with me...

eriksoln, BSN, RN · Jul 8, 2011

I still want you to come work with me...

Well...........TBH, even though my currently employer often gives me the "sinking ship" feeling, my manager just approved a "set schedule" for me that will be wonderful while I am in school.

Healthcare, Customer Service, Real Life and a little help from Mel Gibson.

1. Systematic customer service vs. Individualized customer service

2. Freedom to distinguish good customers from bad customers, and act accordingly

3. The ability to keep business as the primary focus and turn away customers who can't/don't pay

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