• Users Online: 143
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2017  |  Volume : 29  |  Issue : 3  |  Page : 173-178

Patient satisfaction - Mission impossible

Medical Director, Mulamoottil Eye Hospital, Kozhencherry, Kerala, India

Date of Web Publication30-Jan-2018

Correspondence Address:
Dr. Ashley Thomas Jacob
Mulamoottil Eye Hospital, Kozhencherry - 689 641, Kerala
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/kjo.kjo_47_17

Rights and Permissions

Achieving patient satisfaction in a clinical setting is a perennially difficult yet much sought-after goal for every physician. There are many ways to realize this goal including reducing prices, offering new procedures, creating new amenities, and such. However, none of these tend to produce the elusive loyalty. This review shines a laser focus on ways to increase loyalty among your patients and encourage them to act as your ambassadors.

Keywords: Customer service, loyalty, management, patient delight

How to cite this article:
Jacob AT. Patient satisfaction - Mission impossible. Kerala J Ophthalmol 2017;29:173-8

How to cite this URL:
Jacob AT. Patient satisfaction - Mission impossible. Kerala J Ophthalmol [serial online] 2017 [cited 2021 Jun 13];29:173-8. Available from: http://www.kjophthal.com/text.asp?2017/29/3/173/224293

  Introduction Top

No enterprise can survive without customers. Recruiting new customers, retaining existing ones, and encouraging loyalty among customers are the goals of all businesses. Ophthalmology is no exception.

The various ways to measure customer satisfaction include unstructured surveys in the form of “feedback forms,” customer satisfaction surveys (C-SAT), Net Promoter Score (NPS), and customer effort scores (CES).

Research has consistently shown us that it is three times as difficult to acquire new customers than to retain existing ones. Any eye care provider who seeks to increase the volume of new registrations will find the cost of acquisition of a new patient nearly 4 times the cost of retaining existing patients (and their relatives).

Ophthalmologists and Eye Care Centers can increase patient loyalty by implementing simple strategies that include solving patient problems at the first opportunity, deciding what services to offer and not offer, encouraging self-help on the website or app, ensuring continued care, provide easy accessibility, and training the ancillary staff.

“A customer is the most important visitor on our premises, he is not dependent on us. We are dependent on him. He is not an interruption in our work. He is the purpose of it. He is not an outsider in our business. He is part of it. We are not doing him a favour by serving him. He is doing us a favour by giving us an opportunity to do so.”

-Mahatma Gandhi

“Your most unhappy customers are your greatest source of learning.”

-Bill Gates

“Get closer than ever to your customers. So close that you tell them what they need well before they realise it themselves.”

-Steve Jobs

“Customer satisfaction is worthless. Customer loyalty is priceless.”

-Jeffrey Gitomer

  Who Is the Customer? Top

“In the beginner's mind, there are many possibilities, but in the expert's, there are few.” -Shinryu Suzuki, a Zen Buddhist monk.

In this essay, I shall define a customer as anyone who transacts, intends to transact, or is capable of influencing a transaction with any organization. For ophthalmologists, the customer is the “patient.”

This broadens the definition of customer to include

  • Internal customers
  • External customers
  • Influencers.

Internal customers

These are individuals and groups within your organization.

These individuals and groups are responsible for facilitating a transaction by the real customers. Your organization therefore has to “sell” its products, services, or concepts to this group first.

Internal customers are usually employees, management staff, outsourcing partners, suppliers, and service partners. It is critical that this audience is convinced regarding the value system, vision and mission of the hospital because they are on the front lines. Internal customers are usually employees, management staff, outsourcing partners, suppliers, and service partners.

The idea in practice - when a famous eye hospital launched refractive services a few years ago, it found very little acceptance by the community it served. They invested heavily into advertising and marketing, but even after a year of sustained campaigns, the acceptance was very poor. A chance meeting with the founder got me involved in the investigation of this vexing problem. The findings of the investigation horrified the founder. In his previous “avatar” as a nonrefractive surgeon, he had set up a system of incentives for his staff to encourage sales in the opticals business. Sensing that refractive services would diminish their incentives, the employees were resolutely opposed to the adoption of a new technique that was marketed as a “spectacle free lifestyle.” Unfortunately, by the time we analyzed the reason and planned an adequate response, the financial burden was so great that the unit had to be shut down.

External customers

These are individuals and groups outside your organization.

In general, referred to as “customers” by the uninitiated, this group forms the lifeblood of the organization. Depending on the area of the pyramid you targeted, the external customers define you as “value” or “premium” provider.

It is important to remember where your market position is; customers may resist any attempt to crossover to another segment.


These are individuals and groups within or outside your organization who could form, modify, or change the patient's opinion.

Any effort that mobilizes influencers to champion your organization creates what is well known as the “word of mouth on steroids” effect because prospective patients perceive these opinions as unbiased, uninfluenced, and impartial as they have no economic benefit.

  The Effects of Suboptimal Customer Service Top

Before we delve into the techniques to enhance patient satisfaction, let us analyze the consequences of poor customer service.

Service failures (whether real or perceived) not only drive existing patients to search for alternatives; they can dissuade prospective ones too.

Research by Dixon et al.[1] shows that:

  • 25% of customers are likely to say something positive about their customer service experience
  • 65% are likely to speak negatively
  • 23% of customers who had a positive service interaction told 10 or more people about it
  • 48% of customers who had negative experiences told 10 or more others.

Negative experiences generate conversations nearly 2–3 times more often than positive experiences! This is too profound for us to ignore.

  What You Must Avoid: Buyer's Remorse Top

All too often, managers assume that a business transaction has been successful if the customer has completed purchase of the product/service. Organizations encourage this phenomenon by trying incentives to “deal closures.” This is a gross misunderstanding of the customer psyche.

The relationship between a seller and a buyer seldom ends when a sale is made. It is like a marriage where the process of selling can be compared to a courtship, and the sale can be deemed a marriage. As we know from real life, reality begins after the marriage. How good the marriage is will depend on how well the couple manages the relationship and the problems that crop up later. Similarly, the “marriage” to the customer depends on how well the organization manages the relationship after the transaction has been completed. The relationship intensifies after the sale and helps determine the buyer's choice the next time around.

The proof of a successfully managed relationship will be evident in the expanding businesses the customer brings - either for self or from friends and relatives. Like all happy marriages, a well-managed customer relationship will be rewarded with bountiful businesses and goodwill and a divorce will be messy and vengeful!

This is a crucial learning. Eye care professionals must focus on managing the patient relationship “posttransaction” as robustly as they concentrate on the “transaction.”

  We Have No Negative Feedback. Surely We Are Successful!(?) Top

Quite the contrary

There are only two reasons for the absence of negative feedback:

  • Nonexistent patient surveys
  • No candid feedback from patients.

Assuming that the organization performs some form of customer service audits, one of the surest signs of a declining relationship is the absence of complaints from the patient.

Remember - Nobody can be fully satisfied, especially not over an extended period of time.

The absence of feedback might signify a mistrust and/or breakdown of the relationship. A lack of communication is both a symptom and a cause of trouble. Unknown to the ophthalmologist, a dissatisfaction volcano is boiling within the patient pool, and when they finally erupt, it is usually too late or too costly to correct the situation.

  Patient Satisfaction/delight: Is That a Worthwhile Goal? Top

Personally, I am dissatisfied with the term “satisfaction” as it seems to imply that a satisfactory level of service is all that need to be achieved to ensure success.

Many global organizations use customer satisfaction (C-SAT) scores to gauge the customer's experience assuming that a satisfied customer is a loyal customer.

However, consider this report from a study conducted by Corporate Executive Board (CEB): 20% of the “satisfied” customers in the study said they intended to leave the company in question; 28% of the “dissatisfied” customers intended to stay.

We can safely conclude that “patient satisfaction” scores have little merit. At present, we have no metrics to measure “patient delight.” In fact, customer delight is a trumped up version of customer satisfaction and does little much for solving the customer's problem.

The idea in practice: At one eye hospital, they encourage E-mails from prospective clients inquiring about procedures, attributes of procedures, costs, and many more. A simple survey of the “conversion rate” of the E-mails (the percentage of procedures done vs. the number of electronic inquiries) threw up an astonishing number. Their conversion rate was an abysmal 2%!

Digging deep into the reasons, we noted that:

  • Almost 80% of the E-mails had more than 4 threads
  • The prospective patient mailed the organization more than two times (with additional queries) to elicit a “satisfactory” response
  • They had too many options on the website
  • Mailed responses (solutions to customer problems) had many options as well.

We immediately launched an educational program for the employees, cut down the options, offered strong recommendations, and offered solutions to anticipated problems. Pleasantly, we achieved a conversion rate of 38% within 3 months of the program.

Did we create more patient satisfaction or did we create patient delight? I concluded that we did neither! That was not the goal. The goal was to solve the patients' problems swiftly, effectively, and efficiently.

What are the lessons here?

  • Patients want their problem solved with one interaction, certainly not more than two
  • They do not want a list of “options” to choose from
  • They want to solve their problems
  • A strong-willed patient service representative offering a single recommended solution is better than an empathetic individual offering a range of solutions to choose from
  • Delighting patients do not build loyalty; reducing their effort – the work they must do to get their problem solved – does
  • This insight can help improve the quality of the service, reduce service costs, and decrease patient churn.

When it comes to service, ophthalmologists must endeavor to create loyal patients primarily by helping them solve their problems quickly and easily and not by lavishing attention or delighting them with bells and whistles.

  The Ideal Patient Care Representative Top

Imagine this scenario. A postoperative patient calls your help desk with a concern. What type of personality do you want your customer service executive to possess? An empathetic personality or a control freak type?

If you are like most physician managers, you probably picked the empathetic personality type. Research shows otherwise.


The control freak takes charge and assumes leadership.[2]

Why do controllers do better than their counterparts?

Structured interviews done for the study stated above revealed that they are driven to deliver fast, easy service and are comfortable exerting their strong personalities to demonstrate their expertise. They describe themselves as “take charge” people who are more interested in building and following a plan. Controllers focus less on asking customers (patients) what they would like to do and more on telling them what they should do – the aim always being to get to the fastest and easiest resolution.

Interestingly, patients love this!

  Measuring Customer Service Scores Positively Top

Adapted from the Research of Bone et al.[3]

What if instead of asking customers what had gone wrong, companies asked them what had gone right?

Researches consistently found that starting requests for customer feedback by asking for a compliment (such as “what went well during your visit?”) increased reported levels of satisfaction and boosted the chance that customers would purchase again, the amount of money they would spend and their loyalty over time.

Beginning a survey with what the researchers call “open-ended positive solicitations” seems to be an easy, low-cost way to increase satisfaction and spending. People are happier when they focus on the positive, yet companies frequently ask them for negative feedback.

Psychologists know that memory is malleable, so asking customers to recount positive experiences may make the memories of those experiences more salient and accessible in the future enhancing customers' overall perceptions of events. Another psychological effect may be in play as well: cognitive dissonance - which might make customers less apt to think poorly of a brand after having expressed admiration for some aspect of it.

An interesting conclusion of the experiment was that “we compliment what we like, and we like what we compliment.”

A word of caution: do not assume that if you change the wording of a feedback form, people will love you. First, you have to make yourself loveable.

  Customer Effort Score Top

CES is measured by asking a single question: “How much effort did you personally have to put forth to handle your request?” It is scored on a scale from 1 (very low effort) to 5 (very high effort).[1]

The CEB found the predictive power of CES to be strong indeed. Of the customers who reported low effort, 94% expressed an intention to repurchase, and 88% said they would increase their spending.

So what can eye care providers do to reduce the CES score?

Avoid negative words

These are the words that tend to trigger negative reactions and drive repeat calls – “can't,” “won't,” and “don't.” We must focus on coaching our patient service reps to use alternate phrasing to convey the negative message with a positive spin. Instead of saying “Dr. A is not available for consultation” a rep might offer this - “Dr. A will be available after a week, would you like to see his assistant meantime?”

Do not just resolve the current issue – head off the next one

What if your patient service representative not only solves the problem within the first call but also preempts another call by offering advice on anticipated problems? Research shows that this action increases loyalty like no other.

Arm reps to address the emotional side of customer interactions

It is certainly possible to train our reps to handle emotional patients on their level. A bot of empathy at the right moment goes a long way.

Minimize channel switching by increasing self-service channel “stickiness”

Contrary to what we believe, patients love to learn and find the solutions by themselves. The simple act of publishing self-help videos, step-by-step troubleshooting, FAQs, etc., often spur patients to solve the problem without having to call the organization's helpline.

An eye hospital that encourages online appointments and provides a streamlined registration process has solved a major problem facing patients and will certainly derive much positive word of mouth publicity.

Use feedback from disgruntled patients to reduce patient effort

As Bill Gates says there is much to be learned from a disappointed customer. That is why feedback is so important. Ophthalmologists must welcome patients to give candid feedback if they hope to learn.

Empower the front line to deliver a low-effort experience

Finally, it is important to remember that the patient-facing personnel is trained well and equipped with necessary authority to solve patients' problems instead of checking with management every time.

  Customer Loyalty Top

CEB data from more than 100,000 customers worldwide show that interactions with service reps are four times likelier to lead to customer disloyalty than to loyalty. Hence, companies should focus on sparing customers grief rather than trying to delight them with over-the-top service.

Here are some suggestions to “simply solve patients' problems:”

Improve self-service tools

Patients may not need human interaction if self-service channels are simple and intuitive. That does not mean big investments in new technologies. A simple tweak on the website will often suffice.

Preempt repeat calls

Concentrate on “next-issue avoidance.” Patients often recontact hospitals when the solution for their original problem creates a new concern. So be proactive: Help with whatever people call about, but also address issues they are likely to encounter as they implement this solution.

The idea in practice - When a patient calls the nurse to ascertain the correct dosage of a NSAID eye drop, the nurse can preempt the next problem by offering up the information that NSAIDs usually cause stinging and dryness. This makes the patient less tense when the symptoms do crop up and also avoids a messy follow-up call.

  Net Promoter Score Top

This may be the only number you need to know!

Moreover, several leading organizations have invested significant resources to get at this magical number. Personally, I tend to use CES and NPS as they compliment each other.

What exactly is Net Promoter Score?

In this system, you are required to ask just one single basic question to the customer: “On a scale of zero-to-ten, how likely is it that you would recommend this organization or this product or service to a friend or colleague?”[4]

The likelihood is scored from 0 to 10 with 0 denoting that the customer is not likely to recommend and 10 representing readiness to recommend.

Applied to an eye care setting, we use the scores to grade patients as:


People who respond with a 9 or a 10. They are the most loyal patients who make repeat purchases/visits, talk about the eye care provider to friends, participate in surveys, and offer constructive feedback. These are the people you want!


People that responded with 7 or a 8. They are passively satisfied patients who make recommendations with a disclaimer, show little energy and are most likely to defect to a competitor. The goal of the eye care provider should be to engage these patients actively and change their “satisfaction” to “loyalty.”


These are the people who returned a score of 6 or below. These patients are dissatisfied, create disturbances on premises or on social media and bad-mouth the organization to friends and relatives. Ophthalmologists have two choices when faced with detractors:

  1. Solve their problem(s) extremely well, or
  2. If the solution is uneconomic… consciously lose these patients.

To calculate NPS, we subtract the percentage of detractors from the percentage of promoters.

The higher the number, the better. The goal of management must be to continually improve the NPS.

NPS is perhaps a better indicator of patient satisfaction in an ophthalmology setting as the willingness of a patient to recommend the ophthalmologist to a friend or relative signifies loyalty, trust, and happiness to be associated with the service rendered.

  Conclusion Top

Throughout this essay, I have highlighted some critical lessons for the ophthalmologist. These can be summarized as:

  • Remove the extreme effort toward securing patient satisfaction or delight
  • Focus instead, on solving patients' problems
  • Patient satisfaction surveys and C-SAT score are outdated
  • CES and/or NPS are better tools to assess patient loyalty
  • NPS can be used to track the progress of patient-friendly initiatives
  • It is much cheaper to retain existing patients than to recruit new ones.

The basic requirement of any leader is to formulate a strategy for the organization. Seminal works like Micheal Porter's Five Forces Theory, competitive advantage, SWOT analysis, and Blue Ocean Strategy provide great insights into the fine art of strategy formulation, but I shall not discuss them here as they are beyond the scope of this review.

I will leave the reader with one pearl that I gathered from Harvard Business School Professor Frances Frei: “To be good, you have to be bad.”[5]

To the ophthalmologist, it will sound like this: “To be good for most patients, you have to be bad for some patients.” In other words, we cannot be all things to all people. We have to decide what service we excel in and can therefore offer; and what service we cannot offer. The greatest insight of strategy is to decide what NOT to do.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Dixon M, Freeman K, Toman N. Stop trying to delight your customers. Harv Bus Rev 2010.  Back to cited text no. 1
Dixon M, Ponomareff L, Turner S, DeLisi R. Kick-Ass customer service. Harv Bus Rev 2017.  Back to cited text no. 2
Bone SA, Lemon KN, Voorhees CM, Liljenquist KA, Fombelle PW, Detienne KB, et al. “Mere Measurement Plus”: How Solicitation of Open-Ended Positive Feedback Influences Customer Purchase Behavior. Journal of Marketing Research 2017;54:156-70.  Back to cited text no. 3
Reichheld F. The Ultimate Question 2.0: How Net Promoter Companies Thrive in a Customer-driven World. Boston, USA: Harvard Business Review Press; 2011.  Back to cited text no. 4
Frie F, Morriss A. Uncommon Service. Boston, USA: Harvard Business Review Press; 2012.  Back to cited text no. 5


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Who Is the Customer?
The Effects of S...
What You Must Av...
We Have No Negat...
Patient Satisfac...
The Ideal Patien...
Measuring Custom...
Customer Effort ...
Customer Loyalty
Net Promoter Score

 Article Access Statistics
    PDF Downloaded159    
    Comments [Add]    

Recommend this journal