The Customer is NEVER Right - A Nurse Practitioner's Perspective
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For those who missed the presentation at "The Future of Healthcare" Nursing Conference 20-27 Apr 2015 these are the words and graphics to the presentation. Numbers in parentheses (#) corresponds to the PowerPoint slide. 


(1)  I AM A NURSE!

(2) I am not…a bellboy at your favorite resort looking for a tip…I am not a cashier at Chick-fil-A whose script it is, “My pleasure”…I am not a hospital’s CEO chasing satisfaction scores…and most DEFINITELY I am not anyone’s punching bag!

(3) Having gotten that off my chest let me tell you a little about me.
At 16 I attended a vocational school for a LPN program and under the supervision of our instructors I gave care to patients.
At 17 I joined the US Army to be a Combat Medic. After 10 years of active-duty I left the military I love so much to earn my Bachelor of Science in Nursing. Twelve-years ago I earned degrees of a Nurse Practitioner and Clinical Nurse Specialist.
Like so many here, I am a member of a time-honored profession and a patient advocate, responsible to care for the sick, promote health, prevent illness and injury and maintain levels of health for others. As healthcare worker it is our responsibility to cultivate our profession and steer it in the right direction while placing patients’ reasonable concerns ahead of our personal convenience, pleasure, profit and safety without bias, stereotype or compromising the contributions of other healthcare workers.

(4) Because of that camaraderie I wrote the “The Customer is NEVER Right”, not as a disgruntled worker, as this is not about me, but because it is the story of so many in healthcare and a story that had to be told.
The book’s title is purposefully provocative. It not only points out that those who complained in the book were not right but more significant it screams that addressing patients as customers is NEVER right.
I ask you not to judge my words but to judge my intent as the time for conversation has long past and now is time for action.

Not any action, (5) as we have already tried that. We need action that takes healthcare out of the hands of outsiders who have taken it down the wrong tracks. Action that puts healthcare back in the hands of healthcare workers who will steer it in the right direction, where healthcare and healthcare workers come first and everything else follows.

(6) After writing the book I struggled with whether to publish it as I knew that once public there was no turning back. That likely is the reason why so many balk, as anyone here could have written the same, but no one wants to be unemployed.
However, integrity is choosing your thoughts and actions based on values rather than personal gain or fears.

(7) My concern was not critics but rather if I would forever hinder my opportunities in healthcare as the book is inflammatory towards the current system, those managing it and most concerning those offering the jobs.

Recalling words from (8) Robert F. Kennedy’s “Day of Affirmation” speech in 1966, “Few men are willing to brave the disapproval of their fellows, the censure of their colleagues, the wrath of their society…” I took a deep breath and took the plunge. As a result here I am today—looking for work.
I wish I could tell you all this inspiration is a transient epiphany and that after being knocked down a few more times I will dust myself off and finally align myself with just being one more in the crowd looking away.

(9) However, I have been with my guardian angel for a long time and she sees it differently. And just so you know, my guardian angel stays busy watching over me and is not frolicking like the angels at this resort’s front entrance. So here goes nothing…or as my guardian angel so frequently says, here goes everything, AGAIN!

(10) Let me begin by pointing out the obvious, healthcare is like no other industry and:
-the only industry with patients
-the only industry genuinely dedicated to helping others
-the only industry in which services are sought during some of the worse moments of our lives and during inconvenient times, for uncertain, unpredictable and volatile choices in places that are unknown, unpleasant and unforgiving
-the only industry where regardless of disposable income or time services are sought after and rendered
-the only industry where workers are extensively VETTED before trusted with doing our jobs despite we attend accredited schools, are finger-printed, are recertified at least every year for one thing or another, and undergo recredentialing at least biyearly to ensure we did not commit some wrongdoing our employer was not aware of
-the only industry whose workers maintain the public’s confidence year after year as the public has recognized us as the most honest profession and with the greatest ethical standard of any other industry
-most notable, healthcare is the only industry where workers go to battle for every “so-called customer” and when “so-called customers” succumb—we cry for them as well
-lastly, healthcare is the only industry with our waiting room (11) (Video)


(12) Why is healthcare then compared to other industries when the similarities are so minute and the differences colossal? Not to mention, if we are VETTED so extensively and the public holds us with such high regard, why are complaints against us taken at face value over our rendition?
We have the planet’s greatest healthcare system and that is thanks to the men and women in our ranks as it is they who provide such great healthcare. Yet, healthcare in our nation is in crisis, a silent crisis as so many choose to look away.

This silent national crisis is not political although some would disagree. However, we only have healthcare’s submissive, altruistic and accommodating culture that was swayed by outsiders to blame. Not only did we follow the MASSES we turned over the reins and since outsiders have taken healthcare in the wrong direction with their (13) IDIOTOLOGY that it was in the patient’s best interest.


Outsiders like, (14) Fred Lee, (Video) who is not a healthcare worker but was once, or twice, a healthcare administrator.
Lee and those like him cannot be blamed for healthcare’s troubles and much less for them drooling over the almost $4 trillion currently spent on healthcare, as they have only found a need to fill. I wish I made $10,000 per speech engagement.

However, I find it troubling that no one in healthcare challenges these outsiders who claim to be on healthcare’s side. Let’s listen to those words again where healthcare is compared to being, “(15) Just like a waitress.(Video)
A waitress! REALLY!?! That is pretty loud and clear. Yet, so many missed it and those who say they heard it never challenged Lee and that is bothersome as it infers that healthcare administrators agree with Lee’s assessment of our industry.
Just to be clear there isn’t anything wrong with being a waitress. HOWEVER, NO ONE IN HEALTHCARE IS A WAITRESS! NO ONE!

(16) “According to a 2009 Healthcare Advisory Board report, patient satisfaction scores have been stuck at about 82% for the past 10 years!” In other words, we spent hundreds of millions of dollars in those 10-years and have nothing to show for it but the collateral damage left behind.

(17) Not to mention, those numbers are par for the course as they seem to be the average as to how customers rate companies, regardless of industry. Andsomething I been saying for sometime after an administrator pointed out to me that, “Conflicts between customer satisfaction and healthcare workers jeopardizes the administration’s goals of customer retention.”

As if not enough, the same outsiders have now taken their lack of ideas and repacked them as “(18) The Customer Experience”. And guess who is buying into it? Healthcare! As a result it will not be long before we no longer call patients customers or clients but instead we will call them our GUEST!
In addition to the Lee-types there are the Press Ganey-types who are also drooling over the trillions spent on healthcare. The Press Ganey’s being well known to healthcare workers as they have been a thorn in our side for some time.
Different from the Lee’s, the Press Ganey’s use guerrilla tactics to intimidate healthcare administrators into believing that “…the train has left the station…so either get on or be left behind as customer satisfaction and customer satisfaction scores is where healthcare is headed”. Sadly, there is no voice opposing that, despite the train is headed on a collision coarse, as Press Ganey’s IDIOTOLOGY is not sustainable, and healthcare administrators are well aware of that, as many confess that the numbers do not match up.

But none have the testicular fortitude to push back so they bow and keep (19) throwing money at it and say the same things over and over, “Then, gentlemen, it is a consensus of this meeting that we say nothing, do nothing, and hope it all blows over before our next meeting.” Meeting adjourned!
Praying on healthcare’s submissive, altruistic and accommodating culture outsiders have been able to herd healthcare as they desire and will continue to do so by force-feeding them the Kool-aid that has gotten us where we are today.
In turn, healthcare administrators then regurgitate the undigested Kool-aid, like that of scripts and signage, standard uniforms, valet services, luxurious lobbies and even curtsy, to name a few, as being in the patient’s best interest. And those of us who decline to be force-fed are dismissed.
No one, not even the patients themselves, has the patient’s best interest in mind than those of us caring for the patient. That is the reason the public appreciates our honesty and ethical standards, an honor that excludes administrators and outsiders, and righteously so.
Healthcare is a time-honored profession trusted with saving lives and stomping out disease and must NEVER be degraded to just accommodating the exaggerated unrealistic emotional expectations of a few.

(20) Before some of you walk out in objection because of this seismic paradigm shift I am sharing, let me share something else with you. By far, the overwhelming number of patient experiences is unquestionably rewarding, for both healthcare workers and patients.

(21) However, because of their sheer volume those positive experiences become blurs of one another and unless they are remarkably extraordinary their details are consigned to oblivion. On the flip side, the melodramas of the complaining minority are permanently etched in our memories, as the feared consequences of those conflicts become the bane of existence for many healthcare workers, thus our frustration and not fatigue from wanting to help others.

(22) On that note, to those drinking the Kool-aid, do us all a favor, quit writing articles and self-help books that tell us that our frustration is because we are experiencing what you have labeled as, “compassion fatigue”. No one fatigues from helping others. What we fatigue about and are frustrated with is a system that treats us as doormats for others to wipe their feet on.

What is the collateral damage I mention?
The belief was that by increasing customer satisfaction in healthcare it would improve its quality and cost. However, current satisfaction surveys focus on wait times, pain management and communication skills. All of which could be argued DO NOT affect the quality or cost of healthcare.
On the other hand, variables that DO affect the quality and cost of healthcare, such as outcome and the safety of patients and healthcare workers, are omitted from those surveys.

As if exclusion of the latter were not IDIOTIC on its own, to make matters worse, (23) the federal government intends to punish those with low satisfaction scores by reducing their Medicare reimbursements to low.
Those actions will only undermine those with less-than-stellar scores causing them to close their doors. Because after being reimbursed at a lower rate a low-performer will rashly spend its money to correct the customer service inefficiencies rather than improving its product, healthcare. As a result a vicious cycle ensues of losing money without fixing the problem. A lose-lose situation.

Another bad idea is that of tying healthcare workers’ compensation to satisfaction ratings (24) as normal human behavior tempts us to take the path of least resistance. Meaning, if I am going to get paid more for pandering to maintain high satisfaction scores, not to mention keep my job, than I will pander to that IDIOTOLOGY regardless it parallels inappropriate admissions, diagnostics, procedures and medicines.

(25) That, despite studies have shown that the most satisfied patients not only spend the most on healthcare and prescriptions they are also most likely to be admitted and most likely to die. How does that improve the quality or cost of healthcare?

(26) I do not hide behind patients for any reason and prefer to make the argument that taking care of healthcare workers would improve cost and quality and as a bonus would bring online everything healthcare administrators long for, like profits and patient loyalty. That is not a fantasy as successful companies have shown that to be a reality over and over.
I have no knowledge what healthcare organizations spend to sway patients to their facilities. What I do know is that whatever that monetary value is they would benefit most if they spent it on their workers.
The same goes for compensating us for JUST satisfying patients when a greater return on investment would be if we were compensated for outcomes. That is a win-win scenario.

In 2011, the (27) Centers for Medicare and Medicaid Services spent $226 BILLION on overtreatments. That was not just $226 billion for medicines and procedures that did not benefit anyone. That was $226 BILLION WASTED!
How many unnecessary admissions, diagnostics, medications or procedures are ordered just to satisfy patients who say, “But I have insurance…” or patients who believe that every sneeze is swine flu, every headache is a tumor, that their bronchitis is cancer, that their stomach flu is Ebola or that grandma would benefit from a four-day weekend admission. And JUST to avoid a complaint we bow and accommodate those extravagant expectations.

Making matters worse, rather than discounting those as waste, healthcare pundits want to label those inconsistencies as ethical dilemmas—the dilemmas being the need to please patients at any cost, regardless if inappropriate. And why topics like smoking, alcohol, drug abuse, obesity are not to be discussed if unrelated to the visit as (28) those concerns might upset patients.
I caution you from challenging those so-called ethical dilemmas as immoral misjudgments. As I very well know that healthcare worker who are not onboard with the whole customer satisfaction thing will lose that argument and likely their job as well. Not that I doubt you could not defend your position but because administrators have already made up their minds, before addressing the issue with you, that you are a greater risk than a benefit to the organization, as their group thinking only permits them to believe that conflicts between healthcare workers and customer satisfaction jeopardizes their goals of customer retentions. Been there. Done that. Wrote a book about it.

The $226 billion wasted does not include the BILLIONS lost as a result of healthcare directed violence. (29) A violence that has become more frequent, more brazen and more violent despite it has been studied, documented and reported extensively. Let me correct that, reported extensively by others as reports from victims continue to be greatly underreported. Not to mention, despite all that studying, documenting and reporting by others they have nothing to show for it. As conflict resolution and aggression management policies proposed by those professional and government agencies are IMPOTENT as they purposely fall short as to not offend patients or families.
Making matters worse, those dubious IDIOTOLOGIES intended to improve healthcare have done nothing but ignite a survival of the fittest race that has resulted in decreased access as volumes of healthcare centers fold in trying to keep up with the competition. Or UP THE STREET as healthcare administrators disgracefully have labeled our treasured colleagues.
Despite not having the numbers of patients gained versus patients lost there is not much to be gained by spending millions just to sway a few to your side. Especially since a few from your side will likely go to the other side as that is the normal cyclic trend of customers, in every industry. Some you gain and some you lose and that is regardless the negative or positive actions of some.

Think of all the money, energy and time wasted and (30) the collateral damage left behind just to gain some here and some there. Not to mention, whom are you undermining and stealing those patients from? But from our treasured colleagues who are trying to help others as well. As healthcare workers, is that the train we want to be on?
Those are but a few of the collateral damage I speak of and the true reasons as to why so many have left healthcare rather the proposed “compassion fatigue”.

(31) How did we get here?
Well, as Lee said, in the 80’s there was a new frontier in healthcare service excellence… Yet, here we are some thirty years later and billions of dollars wasted, Waitresses.
We got here because healthcare administrators were conned into believing that in order for their organizations to remain open they had to sell their soul to the devil or face closing their doors. Sounds a bit dramatic but that is the gist of it.
How did outsiders persuade healthcare administrators to cross to the dark side? The simplest explanation: Fear mongering. The favored intimidation is that those complained about get sued the most, a very truthful and well-documented fact.
To avoid that potential litigation administrators seek out those who fit their IDIOTOLOGY and those they see a risk are dismissed.

(32) Here is how those who fit are defined.
If the best nurses are those who only get compliments and average nurses are the ones who don’t get either compliments or complaints than I must be the worse nurse ever. But I do not take it personal as I haven’t given one of those shot in a long.
What does bother me is that we let outsiders tell us what we do and who we are.
When instead, the best nurses are NOT the ones who get the most compliments. The best nurses are those who advocate for their patients, promote health, prevent illness and injury, maintain levels of health for others, cultivate their profession and steer it in the right direction while they place patients’ reasonable concerns ahead of their personal conveniences, pleasures, profits and safety without bias, stereotype or compromising the contributions of colleagues or peers with who they stand in solidarity. THAT IS A NURSE! Regardless, complaints or compliments.

Anyhow, those complained about being sued the most is not just a fact in healthcare but a fact in every industry and in (33) every aspect of life, thus not a novelty, as the unhappy always try to find compensation for their so-called woes. Yet, in healthcare a patient complaint causes mass hysteria.
While a fact, those complained about get sued the most, why has no one asked, of those sued how many are dismissed? Because while no one wants to go through litigation being sued does not intuitively give judgment to plaintiffs.
Another question not asked, that should be is, how many sentinel events those who are “POPULAR” cause? Because although not cited in those statistics, we have all heard of that healthcare worker who has caused injury and even death but because “ADORED” that person is kept around.
Myth? I do not know. What I do know is that a number of medical directors have shared those stories with me when they try to console me that life is unfair after they asked me to resign. Yet, when I asked those directors as to why they kept those individuals around a tap dance ensued.
I want to ask, of the two, law suits versus sentinel events, which is more dramatic in the court of public opinion? As that is what this is all about.
Another all too common false narrative is that your hospital will close if patients badmouth your organization because of poor customer service.
I am a nurse and not a businessperson but if you research the whys companies go out of business by far the most common cause is money. Some will argue that poor customer service equals loss in revenue. Although possible, I could not find a single business that closed due to poor customer service.

(34) Does anyone recognize any of those conglomerates? Because according to this article they are the worst at customer service. Yet, some of them are the biggest companies on the planet. Do we want to be known as one of the worse organizations for customer service? ABSOLUTELY NOT! No one is suggesting that, however, do not force-feed me that line, that poor customer service is why businesses fold.

These list vary by author, as customer service is subjective and the difference between being perfect and being great cannot be improved on, measured, scripted, reduced variation or standardized. (35) Those are not my words.

Since when is PERFECT not enough? (36) Did Nadia Comaneci make a PERFECT 10 or did she JUST get a great score?
Being fair to Fred Lee, this is not about bashing him. If anything, I admire his great presentation and oration skills and can see him sending me to hell with such grace that I would look forward to the trip. Not to mention, him selling me things I wouldn’t have a need for in hell, like a lighter. Clearly skills I lack, as I have not been able to convince anyone that I am a benefit rather a risk to any organization.
Nonetheless, the point remains, what are we chasing after? For the difference of being completely satisfied versus wanting the person back again? Is there really a difference or is just semantics?
This is what I learned when I studied this argument. Organizations that do not bring in enough money it is NOT because of customer service. The most common reasons are [1] poor business plans, a common mistake of healthcare, or [2] a product that is subpar to that of the competition.
Regardless of industry, customer service is no more than filler for where the product falls short of the competition’s product. In other words, a great product stands on its own, without fluff or fillers, and products unable to do the same must rely on customer service to make up for its failings.

(37) Of course there are organizations capable of both, a stand-alone product and great customer service. My point, do not be fooled by the false narrative that customer service is the end all. Instead, put your best product forward and in healthcare that is healthcare workers.
Lastly, as to how we got here, the IDIOTOLOGY that conflict between customer satisfaction and healthcare workers jeopardizes the goal of customer retention and profits. As that is the reason why healthcare administrators side with customers, taking their complaints at face value, before siding with their very own and extensively vetted loyal employees.
Because that disregard towards employees only leads to distrust, not just from that one employee, but all in the organization as they all fear of being next if misunderstood. On top of that, it does not help the organization when administrators dismiss that distrust as petty.

What is the answer to getting healthcare on the right tracks? (38) YOU! You MUST take the lead and surround yourself with those on the same mission as you.
The second half of Kennedy’s words was, “Moral courage is a rarer commodity than bravery in battle or great intelligence. Yet, it is the one essential, vital quality for those who seek to change a world which yields most painfully to change.”
Having said that, I caution you, as most healthcare administrators were recruited from clinical backgrounds after they showed interest in looking after and doing good for their clinical colleagues. Sadly, over time those naïve torchbearers find themselves siding more with their NEW administration colleagues than their FORMER clinical associates.
Healthcare administrators already know what I have shared with you, as all of this is public knowledge, yet they have chosen not to lead. Instead, what I been told is, “That is what they are doing ‘up the street’ and so will we.” Meaning, no one wants to go at it alone.
So, the adage “The customer is always right” remains king. Why? No one else is always right. My parents are not always right. My friends are not always right. My siblings are not always right. My grandparents were not always right. My colleagues are not always right. Even I am not always right. So why? Why should anyone accept that the customer is always right?
If you were paying attention, you would noticed I did not say that my wife is not always right. Let’s leave that there, as my guardian angel and my life is sitting in the back of the room.
Some think I am a customer service subject matter expert but I am far from such expertise and much less interested.

What I am a subject matter expert on is patient complaints. As I have the most patient complaints than any healthcare worker on the planet. Because of that expertise I will tell you that complaints come from those with (39) EXAGGERATED UNREALISTIC EMOTIONAL EXPECTATIONS, hidden agendas and grandiose beliefs all extending from entitlement issues or a sense of being VIPs.
Being the patient complaint guru, if I can add anything of value, it would be that although drug seekers might raise hell in your clinic or emergency department contrary to popular belief, they rarely, if ever, submit complains. Drug seekers are not patients. Drug seekers are addicts and the last thing they want is to be banned from their next fix.
In no manner am I suggesting drug seekers get a pass but note that bad things happen to bad people too. What I am suggesting is to not blame drug seekers for your low scores but that you look elsewhere, like at healthcare administrators.
Why administrators? There is no reason why patients cannot or should not complain, as this conversation is not because of patients complaining. This conversation is about the administration’s knee-jerk reactions and sequel JUST because a patient complained.

(40) The literature is inundated with articles that suggest, Why rating your doctor is bad for your health yet no one is interested.

As cited already from Albert Einstein, “We cannot solve our problems with the same thinking we used when we created them.” (41) Because of that, we must rid ourselves of traditional thinking before we can create the future.

For this insanity to end, (42) everything customer service must be deflated to NO more than a byproduct rather than the driving force of healthcare.

Unfortunately, and where the burden lays, (43) healthcare is in desperate need of leadership that will go against the grain, even if it means going at it alone. Leadership that will put healthcare workers and the care we provide first and customer satisfaction to follow. Regretfully, most healthcare administrators are not leaders but managers who merely facilitate policy between subordinates and superiors.
Healthcare needs leaders that are change agents in order to lead in a new direction.

A direction that (44) promotes healthcare workers as valuable and trustworthy,supports our collaboration and professionalism and recognizes us as the good-doers we are for our genuine desire to help others over concerns that patients may take their business to our treasured colleagues.
By no means am I disregarding complaints, but healthcare is much bigger than any complaint and why complaints need not be feared as…

(45) the intent of those who complain is not to get anyone fired but an opportunity for them to vent their frustrations, anxieties and feelings of powerlessness. Disagreement is not a hate crime, or a crime at all. Disagreement is not a lack of compassion or caring either. Who of us has NEVER had a disagreement with those we love most? Yet, those disagreements are not the end of those relationships or the world.

Rather accommodating patient complaints and focusing on customer service and customer satisfaction scores, healthcare needs, and would benefit most, if we placed all our energy, time and money on (46) clinical outcomes and the safety of patients and healthcare workers.
Because not only have we not moved the needle with regard to customer satisfaction scores but after the dust settles, following an incident where a patient complained, what just happened was behavior you would NOT accept at home from those you love most. And you are not alone, as healthcare administrators would not accept that behavior in their home either. Yet, administrators want us to accept that venomous behavior from those we are helping.

(47) I say dismiss those who annoy us. The rude. The entitled. The abusive. The demanding. If we dismiss all those who annoy us, to include the Lee’s and the Press Ganey’s, it frees us to focus on those who value, trust and appreciative us for the care we give. In this we must stand in solidarity and not waiver otherwise those who annoy us will not change their behavior as long as they can find tolerance elsewhere.

Do we really have to mention (48) Solidarity and siding with loyal employees and coworkers over petulant, unreasonable, angry and demanding patients or outsiders looking out for their own interest? This is not about us versus patients. This is about convincing patients that we are looking out for their best interest and if they desire we help them they must stand with us. If they decline then they must leave because asking to see others until they get what they want is manipulative and not what we are here for as it only divides healthcare workers from helping others.

Lastly, as to what needs to happen to get healthcare back is to get rid of the IDIOTOLOGY that got us here in the first place. (49) We must NEVER see the ill or injured as clients or customers but as the patients that they are, ill or injured.

(50) In conclusion, do not throw that line of guilt in our face, that boarding the train is in the patient’s best interest, as I know better and I will not bow to your false narrative and con. Do not tell us we have “compassion fatigue” as no one tires of helping others. We are NOT anyone’s punching bags and neither is a waitress or any worker for that matter. Our desire to help others is to NEVER be taken as us being submissive to anyone, not patients, not families and not administrators either.

(51) I know that I am not alone in these thoughts. And I am well aware of the wrath when healthcare workers do not file in rank to drink the Kool-aid. That being reason enough as to why we have to be bold in taking healthcare back and steering it in the right direction. A direction that puts healthcare workers and the care we provide first and everything else is to follow. Because not only can we save lives and stomp out disease but more so because we will kick butt rising everything else to fall into place, to include patient retention, profits and more importantly employee retention. Anything short of that only leads to resentment, even from those genuinely there to help others.
Thank you for your time and attention. Questions and comments are very much appreciated.

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