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    Julie Ann Bouziotis
    Julie Ann Bouziotis, MBA, FACHE, FACMPE

    The premise of customer service is the how of delivering value downstream, and the concept is more than three dimensional — it also has breadth. Customer service is important in all industries, but it’s especially crucial in healthcare. It is the linchpin in making healthcare costs more predictable for patients. 

    In a recent analysis of reviews from our physician reputation management platform, this feedback resonated: “Since customer service is a lost art, I find the staff and doctor’s approach to patients refreshing.” This pithy feedback is a testament to how critical it is to create positive interactions at every forward-facing patient juncture and realizing that the felix culpa in complex environments is a function of that art at work.

    Customer service is the bedrock of operational success across industries and more so in service-oriented businesses where the “touch” is paramount. For managers with a metiér for quality, they’re acutely aware of the necessity of ensuring all human resource capital is centralized by an ethos of connection and extending that boutique-like feel to their communications and actions longitudinally. Yet, despite its immutable importance, customer service has taken a backseat to many other management manifestations encompassing employee engagement and recognition; this is equally as important. 

    What might not be immediately clear is that the principles of providing excellent customer service can be applied to all types of interactions in a system (human and existential) — not just as an afterthought for a five-star patient experience.

    Let’s consider customer service as a model that influences varying degrees of service and shapes culture. Without a deliberate focus on instilling the key principles of effective, people-centered services across all stakeholders to yield significant outcomes, there remains a huge gap. When observing subpar customer service, I wonder whether employees consider it a Sisyphean challenge or if they just don’t recognize its importance in driving financial success like other revenue-generating imperatives. Good branding means we must make sure staff treat our patients well and understand why this human interaction is vital to our success. 

    Many changes have impacted healthcare delivery in recent years, including how “systemness” synergistically reduces gaps in care, aligns goals across various functions and hyper-focuses on patient satisfaction by addressing common problems. In this context, customer service acts as a bridge between all human interactions within an enterprise, blueprinting how things are done; this is the genesis of creating a culture of interdependence through partnerships and trust. We can no longer myopically associate customer service with frontline work. Instead, it is about tethering storytelling between business units, professions, functions, and both internal and external environments. 

    This article will focus on the outpatient arm of healthcare, as value-based care influences the transition to prevention and moves the lens of health away from episodic care. Our patients first connect with us at the point of service. Customer service in essence is the behavior that leads to satisfaction, including speech, tone and non-verbal cues. Because patient expectations are a moving target, meaningful engagement relies on having the right knowledge and understanding in place. It’s the staff’s expertise and knowledge that solidify their lasting skills and allow them to make the leap from competency to mastery. This learning process is designed to build a high-performing team while also fostering autonomy and self-actualization based on self-confidence and a powerful sense of purpose. What would this look like at the point of service?

    Mastery of:

    1. Insurance rubric and organizational participation
    2. The top 25 CPT® codes and associated diagnoses of that practice
    3. The billing workflow, timing, systems used and interfaced, who the interceptors are reconciling claims errors and the point people behind the scenes managing transactions
    4. Reading and understanding EOBs to speak to expected payment of balances, access and understanding task notes following claims inquiries, and the nature of reimbursements as they relate to A/R
    5. Billing policies, protocols and standard operating procedures surrounding documentation, coding and compliance.

    Since the front desk is the most pivotal point of contact and service in any practice, good customer service must be rooted in the gradient of attention (greeting style and element of kinesthetics) and intention (how much do I know to be able to serve you best). During the staffing search and selection process, one must assess both persona and chemistry with the interviewer and firsthand experience with insurance and billing in the outpatient space. Both aspects are important, but I believe the key question should be whether the staff member understands why they are doing something, along with their ability to effectively carry out the fundamental question: “How can I help you?” 

    Recognizing that patients perceive care through effective storytelling, these front-facing roles play a crucial part in shaping the initial impression of the care quality and showcasing the practice’s commitment and integrity. The patient’s initial experience sets the tone for a series of unconscious biases that affect every interaction during their visit, ultimately influencing their online rating the most. It’s fascinating how some unrefined online reviews can be irrational sometimes due to factors unrelated to the actual care received from the medical provider. This is why training in the art of customer service is so important. 

    When patients in a healthcare system are repeatedly dissatisfied with interactions when they have questions, exceptional competency and mastery become a remarkable and differentiating factor. In an environment where patients often seek information, excellent customer service is about how effectively an employee can create a sense of safety and comfort for the patient, spanning the entire process. If customer service is about, “I am here to help you,” and, “how can I help you,” then the key to its artistic growth and effectiveness is not just knowing what it sounds like but, more importantly, what it feels like. The art of customer service is then a fundamental understanding of a call to action for engagement and connection.

    The spectrum of conversation in our crusade to provide human-centered care is unified by a common theme of belonging. Expanding on this in the context of this article, customer service means the ability to involve the patient by having the necessary tools and the training to provide not only current information but also what is to follow. The art of customer service is about skillfully creating an interaction where engagement and connection coexist by providing the right information at the right time and in the right way. 

    A practical approach to develop this skill is to properly orient staff to the brand and naturally demonstrate its value in connecting patients with its purpose. Creating a welcoming and comfortable environment where patients seek help leads to better adherence because it is associated with the positive feeling of receiving care. After all, at the most basic level, a feeling of belonging is rooted in the sharing of information. During this exchange of “this is how we do things around here,” an attachment is forged.

    The art of customer service is not only about staff behavior. It is also tied to how the operational architect has designed the space, considered how team members interact, set clear expectations, and organized the workflow to create a smooth and impressive experience from the start. This is not uncharted territory in operations, but many registration processes have unnecessary obstacles that go against delivering value.  

    Another important aspect to consider is the friction caused by insufficient training and institutional knowledge that should be given the highest priority to ensure an internal perspective that dominates the outside view. The best services are delivered by highly competent staff who receive continuous education, feedback, and coaching. They have access to information, opportunities to learn from mistakes, effective communication within and across teams, and a commitment to stewardship. 

    Best-in-class performance occurs when each person on the team has been given the tools to succeed and management is held accountable for leadership that prioritizes the success of others and reinforces a culture of learning opportunities and growth. This can be achieved by asking the critical questions needed to get from here to there, such as: 

    • Does patient have a variable experience depending on which staff member they interact with (gap in knowledge/training/performance/expectations/culture/governance)?
    • Does the patient arrive and is advised on scene there is an issue with his/her coverage e.g., no preparedness (friction, dissatisfaction, embarrassment)?
    • Are staff relying on patients to do the work over demonstrating they have all the answers (e.g., patient arrives and is asked what their copayment is)?
    • Do staff yield to avoid confrontation with patient who state they won’t or can’t make the copayment?
    • When a patient has questions about a previous bill, about why charges are so high or about the codes billed, are staff well-versed in the insurance lexicon to appropriately manage these questions or defer patients to the billing office? (Friction, patient frustration and a takeaway of helpless rather than helpful stewards of the registration function)?

    Customer service is about training individuals to overcome the widespread indifference we continue to see across practices toward information sharing, especially in satellite offices. A great way to start filling the void is to invest in helping staff find their sense of purpose. An esoteric framework is not required, just a healthy retrospective view of the basics:

    PDSA:

    1. Create a scorecard balancing behavior and skill for ideal future state best-in-class deliverables.
    2. Perform routine audits across users for repetitive corrective action, creating an ethos of learning and growth opportunities.
    3. Identify contributing factors causing interference and negatively impacting retention of new information such as staffing ratios, spatial impact, adequate access to resources, etc.
    4. Assess the blueprint: Are patients competing for attention in hybrid models where phones are toggled with registration and is there an opportunity to change the model?
    5. Observe whether patients come second to ingroup dialogue and cell phone activity and whether it’s a good time to reset and reinstate the “why.”
    6. Have informal conversations with staff to understand and acknowledge their pain points. What do they identify as “system incoherence”? Do they know how they’re being rated by patients, and do they care? 
    7. Figure out whether there is a sense of responsibility.
    8. Determine whether the team is in balance (experience differentials amongst staff that go unchecked deteriorates interest).

    After the evaluation, if the engineering is deemed optimal, it is time to pivot to the cornerstone of success: assigning a skilled trainer. It’s common for new employees to be paired with senior members, even though experience doesn’t ensure effective training. This approach is risky, especially when training across divisions where consistent methods are crucial. Differences in training can cause problems as tasks build on one another.

    How do we get from here to there?

    Anecdotally, I have seen our clinical nurse manager acquiesce to this approach because of staff shortages. We had many LPNs come and go, affecting our operations; however, she blamed bad hiring rather than considering that the trainer might have been the issue, despite our careful hiring process. I suggested that she, having mastery in this area and despite the relative weight and impact on her own assignments, should be the early trainer until competencies were realized across all new hires. At first, she strongly opposed the idea, but it is now standard operating procedure at the clinic. Taking this approach is paying off. Quality training has long-lasting benefits that grow with time. Learning from an expert provides unique emotional and social insights that build a strong foundation and sense of belonging from the beginning.

    So how do we metamorphose transactions to transformations? We train to master not to serve, and we emerge a strong sense of why to reach the tipping point where patients remember the experience fondly.

    Notes:

    1. Whitmore J. (1992) Coaching for Performance: The Principles and Practice of Coaching and Leadership
    2. Coyle D. (2018) The Culture Code: The Secrets of Highly Successful Groups.
    3. Sinek S. (2009) Start with Why.
    4. Lencioni P. (2017) The Five Dysfunctions of a Team: A Leadership Fable.


    Julie Ann Bouziotis

    Written By

    Julie Ann Bouziotis, MBA, FACHE, FACMPE

    Julie Ann Bouziotis, Department Administrator, Stony Brook Dermatology Associates, Stony Brook University Hospital, can be reached at Julie.Bouziotis@stonybrookmedicine.edu.


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