Eric Legras … THEDOCTORFACTORY … Health & Wellness Strategic Marketing

Do Happy staff = Happy patients? by The Doctor Factory

Staff happiness represents only one piece of a very complex process.

Thomas Jefferson enshrined in this country’s civil religion the “pursuit of happiness” as an unalienable right. But if a medical practice’s staff is successful in that pursuit, does it translate into happy patients?

In a 2009 Harvard Business Review article, Rosa Chun, a professor of business ethics and corporate social responsibility, and Gary Davies, a professor of corporate reputation at Manchester Business School in the United Kingdom, wrote a brief article disputing the conventional wisdom that happy employees yield happy customers. Their study, they say, found no correlation between employee satisfaction and service. But others are skeptical—very skeptical.

Not surprisingly, those on both sides of the issue can point to research to support their position.

“There’s a long line of research that shows that being happy—to the extent that one takes care of personal needs only—doesn’t translate to good customer or patient care,” says Billie Blair, PhD, president/CE of Change Strategies, Inc., and the author of All The Moving Parts (Puzzles Press, 2007).


But, Randy Clark, PhD, an assistant professor in management and marketing at Middle Tennessee State University of Murfreesboro, says that he’s come across numerous studies that talk about a link between employee satisfaction and customer satisfaction—although he acknowledges that the strength of that link varies.


Happy” doesn’t necessarily reflect what is really meant in these discussions, Blair says. The issue is more around employees valuing the organization and their role in it. Being proud of the work they do, and being pleased with their contributions, is what leads to a connection between employees and patients or customers that will lead to satisfaction.

Engagement may be a better term, suggests Nicholas Lavroff, PhD, a retired industrial psychologist and a member of the Patterson, New York-based Taico Incentive Services’ advisory committee. Employee engagement results from the recognition of employees’ contributions to company goals, as well as reinforcement of the employee’s actions through a clearly stated reward and recognition system, Lavroff says. The clearer the association between the employee’s actions and their subsequent rewards, the stronger the connection and the greater the control over the employee’s behavior in the workplace.

Of course, “engagement” can be almost as challenging to appropriately define as “happiness.” Lavroff suggests that true engagement requires:

  • A clear statement about the company’s goals coming from senior management and then echoed by midlevel and immediate managers.
  • An equally clear statement about the individual employee’s role in achieving those goals (including specific behaviors that must be nurtured).
  • A predictable reward and recognition system.

Manoj Pawar, MD, has a broad range of patient experiences as a family physician and a physician executive with expertise in leadership and group culture. Pawar is currently vice president of clinical operations and physician leadership development for Catholic Health Initiatives in Englewood, Colorado. He says that he has tended to use the term “fulfilled” to reflect a combination of happy and engaged employees who believe that they are contributing to something bigger than themselves. It’s a process more complex than smiles and laughter might suggest.

It can be helpful to think about the issue from the consumer’s perspective, Blair suggests. “When I walk up to a customer service desk, I’m not really expecting the person to be ‘happy.’ I want them to attend to my needs and be pleasant. But I also want them to be effective and efficient. That’s very different from a happy employee.” Happy employees, she says, “may be enjoying one another more than serving their customers.”

Arguably, healthcare is different. It is certainly a far more personal, and often intimate, relationship than consumers will experience with retail clerks or service personnel in other environments.

Judy Bee, a medical practice management consultant with the Practice Performance Group in La Jolla, California, and a Medical Economicseditorial consultant, notes that, in primary care, many patients will go out of network because they have a relationship with a provider that is very important to them. That relationship extends to others in the practice environment as well. She adds there is a difference between “boutique practices” and large practices, where relationships are harder to build and maintain.


Still, the question remains: Even if a relationship exists between happy employees and satisfied patients, what is the strength of that relationship?

Although most people would agree that the relationship between “happiness” and satisfaction may not be directly connected, few would agree that no relationship exists. The question then becomes: To what extent does that correlation exist? In service industries such as healthcare, however, it is not unreasonable to expect that the correlation would be higher than in a manufacturing setting, where customers are buying products that may never involve a direct connection between them and the employees who made or shipped those products. In healthcare, the interaction between patients and a practice’s employees is extensive and clearly relevant to the overall service experience.

In fact, Clark asserts, the more service-oriented the business, the stronger the link between employee and customer satisfaction. And, healthcare is a particularly complex service environment where patients typically have a difficult time judging the quality of the service they receive.

“If everything is better the next day, they did a good job. If things still aren’t better, it wasn’t good,” Clark says. “Sometimes, particularly in a medical situation, we view the employees we deal with and their attitudes as a big determinant of whether we’re happy with what we received. If employees seem to like their jobs and seem to be happy in doing their jobs, we assume it must be a good place—they must be happy with what they’re doing and the service they’re providing, and we must be getting good service.”

Michael DiPietro is vice president of marketing and product management for HealthcareSource, a talent management software vendor specializing in healthcare in Woburn, Massachusetts. It is only a matter of time before research is done to find real correlation between employee satisfaction/engagement and patient satisfaction, he says. Drivers include the adoption of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores and the standardization of patient satisfaction scores through the use of surveys.

“I’m not sure that anyone will ever be able to determine clear cause and effect, but I think healthcare human resources professionals as a whole believe this to be the case, and I think it will become a bigger and bigger strategic initiative as HCAHPS scores become more publicized and especially if HCAHPS scores get tied to reimbursement levels,” DiPietro says.


James S. Compton, MD, is an internist with South St. Louis Medical Associates in Missouri. Part of the problem with drawing a direct correlation between employee and patient satisfaction is the multifaceted nature of healthcare experiences, Compton says.

“While happy employees contribute to a positive work environment that can be seen and felt by patients, happy employees are not the only necessary factor for a positive patient experience,” Compton says. Patients, he says, judge their healthcare experiences based on a multitude of factors that include staff, the personality of the physician, the effectiveness and efficiency of the practice, the length of time they have to wait in the waiting room or wait to be scheduled for an appointment, etc.

Hiring for that customer service orientation is a critical first step in strengthening this connection. Karen Zupko is the principal of Karen Zupko & Associates, a practice management and training consultancy, in Chicago, Illinois, and a Medical Economics editorial consultant. She points to two extremes of employees who might be hired into a practice: those who never should have been hired in the first place because they simply “lack the gene” for happiness, and those who came to the practice as happy people but the circumstances, the job environment, or the lack of tools and support they find themselves faced with make them unhappy. Then, there are those somewhere in the middle who wonder why they should try any harder when rewards don’t seem to be forthcoming and when others who exhibit poor performance are allowed to continue on for weeks, months, or even years.

Hiring the right people in the first place certainly matters. So does providing an environment where the right people have the support and reinforcement they need. And even those with a high commitment to service, a positive attitude, and a nurturing environment need some training along the way, says Edward Leigh, founder and director of the Center for Healthcare Communication in Cleveland, Ohio. Leigh finds that patient satisfaction requires skills that must be taught.

“Just because people feel better about their work does not mean they suddenly know how to effectively work with patients,” he says.

He provides an example with regard to patient education, which is an area of significant opportunity for improvement in healthcare. “The problem I see when I coach healthcare professionals is, they’ll explain something very detailed, very lengthy, and with a lot of complexity to a patient, and then they’ll say ‘Do you understand?’—and most patients will say ‘Yes,’ even though they don’t understand.”

Teaching employees an educational strategy called “teachback” can improve their understanding and, ultimately, both satisfaction and clinical outcomes. “Instead of saying ‘Do you understand?’ employees would say something like: “When you go home tonight, what are you going to tell your spouse about your treatment plan?”

The point is that, without information, education, and training about the broad range of interactions staff have with patients, happiness is not enough.

Pawar’s leadership background has led him to realize that engagement is a leadership imperative and a factor of how leadership is expressed throughout the organization. Leaders—physicians—who create cultures that allow people to feel fulfilled will result in both engaged employees and, ultimately, satisfied patients. Although the correlation between the two may not be direct, connections certainly exist.

For instance, he notes, in an office environment where employees don’t feel fulfilled and engaged, or don’t believe that their input and perspectives matter, they may not share pertinent information. Suppose there’s a diabetic patient whose medications have been frequently adjusted with no positive results. The medical assistant happens to know that this person is having a difficult time economically and also frequently observes him coming in with bags of fast food. “If you don’t have an environment where employees feel fulfilled and engaged, they may not contribute that piece of information, and you’ll never be able to provide that patient with the level of care he deserves,” Pawar says.

The effectiveness of employees working together and contributing to a process that results in positive outcomes also is hindered by a lack of engagement, he says. “In an environment of not only high complexity, but where there’s a high emotional context, we can’t afford to have physicians and employees that are not fully present and that are not fulfilled.”

Bee agrees. If employees are working in an environment where they’re angry at the doctors, frustrated with the job, unhappy with the management of the practice because management isn’t “fair,” and are generally sapped of energy on a day-to-day basis, they’re not likely to bounce out of their chair to help a woman at the front door struggling with her hands full of twins and assorted baby paraphernalia.

And, of course, sometimes the fit is simply not right. In that case, says Zupko, the employee needs to be “freed.” “There are some employees whom you don’t need to fire—you need to free,” she says. “They are fundamentally not happy in the environment, and you are not going to change the environment, so free them to find an environment and workplace that values who they are and what they bring to the job.”


Ultimately, Compton says, that ephemeral combination of happy, satisfied, or engaged employees and happy or satisfied patients results in something even more valued: better outcomes. “I believe that satisfied patients are more compliant with medications and medical regimens,” he says. “Every disease has some sort of psychological overlay. Treatment and, to a great degree, prognosis, depend on how you view and understand your diagnosis and treatment plans. The happier the patient, the more they want to understand and participate in their healthcare process and outcome.”

In addition, Pawar says, satisfied employees are likely to stay with the practice longer, resulting in lower turnover and, ultimately, lower disruption that can result in inconsistent experiences for patients and more opportunities for process failures that could lead not only to dissatisfaction but poor clinical outcomes.


“Do happy employees make happy patients? Certainly they create more satisfied patients, certainly more loyal patients,” Bee says. And, when you have employees who will go the extra mile just because they want to and because they have confidence that you support them, you’re going to have patients who say: ‘You know, I hate going in there because I’m sick, or I’m broken, or whatever, but those people are so great I wouldn’t think of going anywhere else.’ “

Employee happiness, satisfaction, or engagement represents only one piece of a very complex process, particularly in a service industry such as healthcare. Despite the obvious importance of satisfied employees, medical practices must focus on the entire service delivery process to ensure that all of its parts are working together effectively to deliver the highest levels of patient satisfaction. In these days of healthcare reform, this practice no longer is simply “nice” or “something to think about”—it may well be necessary to do to remain viable in an increasingly competitive environment.


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