Download From Customer Satisfaction to Customer Bliss

From Customer Satisfaction
to Customer Bliss
Optimizing Your Customer’s Experience
Sergei Kochkin, Ph.D.
Better Hearing Institute
Topics to be Covered
 Defining
consumer satisfaction
 Importance
 What's
 Actions
of consumer satisfaction
important to the end user
to improve customer satisfaction
Defining Customer
Satisfaction
What is customer satisfaction &
what is benefit?
Aim of Marketing
The aim of marketing is to acquire,
retain and satisfy customers. Those
firms (practices) which understand
the needs of their customers and
seek to satisfy them tend to be more
successful than those which do not.
Meaning of Satisfaction & Benefit

Benefit:
• Enhance well being
• To be helpful or advantageous to
• To improve or gain advantage

Satisfaction:
• To gratify the need, desire or expectation of
• To fulfill a need or desire
Some Synonyms for Satisfaction
Adequacy
Adequacy
Acceptability
Acceptability
Agreeability
Agreeability
Sufficiency
Sufficiency
Fulfillment
Fulfillment
Comfort
Comfort
Happiness
Happiness
Serenity
Serenity
Peace
Peace of
of mind
mind
Gladness
Gladness
Gratification
Gratification
Delight
Contentment
Contentment Delight
Well
Well being
being
Amusement
Amusement
Relief
Relief
Cheer
Cheer
Euphoria
Euphoria
Elation
Elation
Rapture
Rapture
Keen
Keen pleasure
pleasure
Cloud
Cloud nine
nine
Ecstasy
Ecstasy
Bliss
Bliss
Exhilaration
Exhilaration
Heaven
Heaven
What is Customer Satisfaction?
 Whatever
the customer says it is.
 The
extent to which hearing aid benefit
meets consumer needs.
 Clinical

definition (Vanderbilt Report II):
"a change between unaided and aided
speech communication ability"
What is Customer Satisfaction?
“Customer satisfaction not only
involves assuring the quality of the
product or service provided, but also
meeting the consumer's need as an
individual.”
Douglas Heath - consultant
The Key to Growth &
Competitiveness

To Satisfy is to meet consumer needs:



Consistently generate satisfied customers.
Will give you their repeat business.
Will promote your business for you.

To accelerate growth we need to create "blissful"
customers

"Blissful" customers will become apostles for
your business.
Importance of Customer
Satisfaction
Business is made up of the largest
group of volunteers in the
world......customers!
Consumer Satisfaction is Important to Health
of Hearing Aid Industry
Would you repurchase brand of hearing aid?
Consumer Satisfaction is Important to Health
of Hearing Aid Industry
Would you recommend hearing aids to your friends?
Consumer Satisfaction is Important to
Health of Hearing Aid Industry
Would you recommend the dispenser who fit Your H.A.?
Reasons for Non-purchase of
Hearing Instruments
$19 billion dollar loss to
audiologists & dispensers
Impact of Dissatisfied Customers
 Deming
proved that a dissatisfied
customer tells 16 other people but a
satisfied person only 8 others.
 Negative
word-of-mouth has blocked
close to 4 million from purchasing our
product in the U.S.
 Potential
$19 billion loss to dispensers.
Impact of Customer Dissatisfaction
 No
initial sale of the product
 No
repeat purchase of the product
 Negative
word-of-mouth advertising
 Less
referral business
 More
bad debt write-offs
Impact of Customer Dissatisfaction
 Higher
employee turnover & absenteeism
 Lower
staff morale
 Lower
compliance with instructions
 More
malpractice suits
 Lower
profitability
What Customers Want
Relative Importance of Factors on Overall
Consumer Satisfaction
Top 4 explain 96%
of variance in
overall
satisfaction.
Impact of Improving Multiple Environmental
Listening Utility (MELU) on Overall Satisfaction
% Satisfaction
(All hearing aid owners n=2,572)
100
90
80
70
60
50
40
30
20
10
0
78 77
82
89 90 89
66
51
58 56
37
27
18 19
9
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14
Number of Listening Situations Satisfied
Relative Importance of Factors on
Overall Consumer Satisfaction
Summary of Consumer Needs –
Four Methods

Factors </= 40% satisfaction.

Factors most related to overall customer
satisfaction.

Improvements sought in hearing instruments.

Reasons why hearing instruments are in the
drawer.
Factors < / = 40% Satisfaction






Hearing in noise
Hearing instrument usage in large groups
Hearing instrument usage on telephones & cell
phones
Hearing instrument usage at concerts and
movies
Whistling, feedback and buzzing
Comfort with loud sounds
Factors Most Related to Overall
Customer Satisfaction

Benefit at a good value

Better sound quality

Better Reliability

Multiple Environmental Listening Utility (MELU)
Hearing Aid Improvements Sought by Current
Hearing Aid Owners (n=2,428)
(Highly desirable scores =4-5 on 5 point scale)
Speech in noise
Better sound quality
Less whistle/buzzing
Lower price
More soft sounds
Longer lasting batteries
Work better on telephone
Loud sounds less painful
Speech in quiet
Better fit & comfort
Should have VC
Longer money back guarantee
Less costly to repair
95
88
85
84
83
82
82
81
81
79
77
74
73
0
10
20
30
40
50
60
70
% highly desirable
80
90 100
Hearing Aid Improvements Sought by Current
Hearing Aid Owners (n=2,428)
(Desirable scores =4-5 on 5 point scale)
Easier to regulate volume
Mask tinnitus
Easier to clean
Work better on cell phone
Better sound to music
Should not break down as much
Less visibility
Easier battery change
2-5 year payment plan
Should have remote
More fashionable
Color
Lease hearing aid
72
71
66
63
62
56
52
48
34
32
28
21
15
0
10 20 30 40 50 60 70 80 90 100
% highly desirable
Improvements Sought in Hearing
Instruments
 Speech
intelligibility in noise
 Better sound quality
 Less whistling & buzzing (feedback)
 Lower price
 More soft sounds audible
The Consumer’s
Perspective:
“Why My Hearing Aids
Are in the Drawer”
Methodology
 National
surveys of U.S. Hearing aid
Market since 1989.
 National family opinion panel
80,000 households
13,492 hearing-impaired households
 Detailed
questionnaire 2,720 hearing
aid owners.
 Response rate 83%
Methodology
 Consumers
who own a hearing aid but
NEVER wear it = hearing aid in the
drawer.
 Hearing aids in drawer = 16.2%
respondents.
 Told to explain why non-use in MarkeTrak
survey.
 Received 348 letters.
 Content coding yielded 567 comments.
Hearing Aids in the Drawer are
Related to Age of the Instrument
But a third are New Hearing
Instruments
120
325,000 1-4 years
Volume
(000)
100
80
60
40
20
0
1 2 3 4 5
6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Age of hearing aid (years)
What are the top 3 reasons
why hearing aids are in the
drawer?
Reasons for Non-Use
 Poor
benefit (30%) - 268,507
Reasons for Non-Use
Poor Benefit
“I threw it away it was worthless to me”
“I don’t see much difference with them. I feel I
was sold one under false pretense. Don’t feel
I really needed one”
“There is no improvement in my hearing with
the aids. Where there is a slight
improvement in my hearing, it is minimal.”
Reasons for Non-Use
Poor Benefit
“I don’t wear the aids at all. The
problems appears to be clarity of
words. Volume is OK but I can’t
distinguish words”
“I have not been able to wear the H.A.
since the day I received it. It was made
wrong and the Company said there was
nothing wrong with it.”
Reasons for Non-Use
Poor Benefit
“It is not worth the trouble or expense for
the small difference in hearing. I wish I
had my money back.”
“_____ aims at taking old people’s money
for little value.”
“All the aids do is amplify the sound that I
can’t discriminate with an aid in the ear.”
Reasons for Non-Use
Poor Benefit
“When ______sold me the H.A., I was
confident it would help me hear better.
When I received it and wore it every
day, it did not make my hearing any
better. So, I don’t wear the HA and feel
like I wasted my money. I tried to
return it and the person did not seem to
want to help me. I am quite dissatisfied
with the whole experience.”
Reasons for Non-Use
Poor Benefit
“I can’t hear high pitch sounds with the
behind the ear model.”
“H.A.s amplify everything but human
voices which is what you need to hear.”
“____plugs are not worth the price.”
Reasons for Non-Use

#1. Poor benefit (30%) - 268,507

#2. Background noise (25%) - 229,383
Reasons for Non-Use
Background Noise
“I will not wear my H.A. because it increases
background noise. And therefore, after a
while I get a headache and get somewhat
nervous.”
“It catches all the sound on the road, TV, etc
at the same time.”
“Background noise is distracting.”
Reasons for Non-Use
Background Noise
“H.A.s don’t work when there is a lot of
background noise. This is when you need
them to work.”
“Background noise really drives him crazy.”
“My problem is with background noise. All
my H.A.s do is amplify so they are of little
help.”
Reasons for Non-Use
Background Noise
“I don’t wear my H.A. because I need it at a
dance, restaurants, and large groups.
All the H.A. does is increase all sound
including background sounds. No help.”
“Sudden loud noise is a killer.”
“H.A. amplify other sounds so much that I
actually feel pain.”
Reasons for Non-Use
Background Noise
“If someone drops a spoon on the table it
is like a rifle going off.”
“Hate them. They don’t work for me. All
sounds are amplified. Never knew
there were so many. I can’t adjust the
H.A. constantly to every noise.”
Reasons for Non-Use
 #1.
Poor benefit (30%) - 268,507
 #2. Background noise (25%) - 229,383

#3. Fit & Comfort (19%) - 169,431
Reasons for Non-Use
Fit & Comfort
“My hearing aids are too big for my ears.”
“It is uncomfortable and my wife says I don’t
listen to her anyway.”
“It hurts my ears.”
“I do not like the feel of it in my ear.”
Reasons for Non-Use
Fit & Comfort
“I don’t wear my H.A. because they plug
up my ears and feel uncomfortable.”
“My H.A. has the tendency to fall out when
I am working hard in hot weather.”
“It’s hard to keep it in my ear. I travel for
business a lot and can’t risk it falling out
of my ear.”
Reasons for Non-Use

#1. Poor benefit (30%) - 268,507
 #2. Background noise (25%) - 229,383
 #3. Fit & Comfort (19%) - 169,431

#4. Negative side effects (11%) - 99,048
Reasons for Non-Use
Negative Side-effects
 Ears
that hurt
 Too much pressure in the ears
 Blisters in ears
 Rashes in ears
 Itching ears
 Dizzy
 Nervous
Reasons for Non-Use
Negative Side-effects
 Ears
that sweat
 Builds up wax in inner ear
 Headache
 Hair gets caught in hearing aid
 Infections in ear
 Problems chewing or swallowing
 Plugs up ears
Reasons for Non-Use
 #1.
Poor benefit (30%) - 268,507
 #2. Background noise (25%) - 229,383
 #3. Fit & Comfort (19%) - 169,431
 #4. Negative side effects (11%) - 99,048

#5. Price & cost (10%) - 93,839
Reasons for Non-Use
Price & Cost
“I bought the H.A. when I was teaching. I
had trouble hearing student’s
questions. Since retiring I have stopped
using them. They were costing too
much for what good I was able to get
from them.”
“Programmable H.A. would be desirable
but they cost too much.”
Reasons for Non-Use
Price & Cost
“My current H.A. are broken & I am
unable to afford the cost of a
replacement. They are too old for
service.”
The expense of owning and maintaining
are too great.
HMO does not cover for HA. Price is
high.
Reasons for Non-Use
Price & Cost
“I enjoyed my H.A., but they burned up in a
house fire and I can’t afford another one.”
“I wish an aid would be developed to allow
us to hear natural sound and an aid with a
reasonable price.”
“If I could afford it, I would buy a different
brand.”
Reasons for Non-Use
Price & Cost
“My H.A. was never dependable. Taking
it in for an adjustment was only a
headache as it never performed very
long. Had to be looked at again. The
last time I had trouble, the office
wanted to send it to _____ at $200 &
just to check it, plus another $200 to
repair it.”
Minor Reasons for Non-Use
 #6.
Don’t need help (8%) - 72,987
 #7. Broke or does not work (8%) - 68,814
 #8. Sound quality (6%) - 57,329
 #9. Won’t wear - unspecified (6%) - 57,556
 #10. Volume control adjust. (5%) - 44,314
 #11. Whistling & feedback (4%) - 39,100
 #12. Nuisance / hassle (4%) -38,371
 #13. Poor service (3%) - 28,673
 #14. High frequency Loss (3%) - 26,067
Minor Reasons for Non-Use
 #15.
Stigma of wearing (3%) - 26,037
 #16. Profound hearing loss (3%) - 23,460
 #17. Work in limited situations (3%)-23,460
 #18. Uncomfortably loud (2%) - 27,114
 #19. Battery life (2%) - 19,186
Very Minor Reasons for Non-Use
1% or less of mentions






Does not work on
phone
Monaural aids
inadequate
Expectations not met
Has Tinnitus
Manual dexterity
Forget to use







Family pressure
Feels like ear plugs
Poor directivity
Low gain
Lost hearing aids
Ear wax problem
Rare social user
Key Findings
 907k
inactive hearing aid owners in the
United States (1997).
 Key



reasons:
Poor benefit
Background noise
Fit and comfort
Dispenser has control over hearing
aids in the drawer
#






1. Poor benefit:
Use programmable technology (analog or DSP)
Pre-post benefit measurement
Real ear measurement
90 day post fitting customer satisfaction survey.
100% money back guarantee
Aural rehabilitation
Significant impact on hearing aid satisfaction.
Return rates been shown to be cut in half.
Dispenser has control over hearing
aids in the drawer
#







2. Hearing in noise
100% use of dual microphones – not just in high-end
product
DSP for comfort in noise
Volume control necessary for some segments
Manual omni/directional switch necessary for some
consumers
Binaural fitting for bilateral loss customers (85% rate
in US- much lower in Europe)
Deep-fitting CICs give some benefit.
Aural rehabilitation
Dispenser has control over hearing aids
in the drawer
 #3.
Fit and Comfort
 Extreme vigilance during impression taking.
Multiple shell impressions if necessary with
“best” going to the manufacturer.
Silicon material considered superior.
 Explore emerging soft shell technology for difficult
cases.
 Rework within office.
 Assess manual dexterity and visual acuity
considerations relative to hearing aid style.
 14 or 30 day trial post-fitting subjective measure of
fit and comfort.
What Can the Industry Do
to Improve Customer
Satisfaction?
Customer Satisfaction is a
Complex Issue
What Needs are we Trying
to Meet in the Hearing Aid
Market?
We are Not in the Business of Selling
Hearing Aids!
We are here to meet deep seated human needs










To improve speech intelligibility
To improve hearing in all listening situations
To improve communication
To enhance belongingness
To facilitate acceptance
To reduce free-state anxiety
To increase comprehension
To enhance enjoyment of life
To enhance psychological well-being
sometimes even SAVE LIVES
Develop a Mission Statement for
Your Practice

Involve all staff & make sure they understand and
buy into the mission.

Make it idealistic.

Talk from your heart.

Display it prominently.

Hand out to each customer as if it were a contract.
Sample Mission Statement
Our mission is to improve the quality of your life,
to improve the relationship between you and
your family, to enhance your ability to belong
and contribute to your community. We will do
everything possible to assure your satisfaction
with our service and our product. If you are not
completely satisfied we are not satisfied.
The staff of XYZ Audiovestibular Services
Use the Findings From the NCOA Study

Become very familiar with the executive
summary of the study


Counsel your potential clients on the benefits
of hearing aids.



Kochkin & Rogin. Quantifying the Obvious : The
impact of hearing aids on quality of life (Hearing
Review, Jan. 2000)
Talk about the powerful human benefits
Spend less time selling technology or size
Develop a presentation of the key results
(e.g. Powerpoint)

Use my PowerPoint presentation if you want
Use the Findings From the NCOA Study

Develop a small quality brochure on the key
benefits of hearing aids:




Your business
Local Association
National Association
Begin collecting powerful human interest
stories from your practice which are related to
quality of life changes and use them to "sell":



Part of your counseling protocol
Radio/public appearances
Quotes in direct mail pieces
Use the Findings From the NCOA
Study

Develop 10-15 minute professional video on
"real" quality of life changes using your State
and National Organizations.



CNN type human interest vignettes
Key findings of NCOA study
Multi-function video
 Physician education
 Consumer outreach
 Local media outreach
Use the Findings From the NCOA
Study

Share the information with physicians and
managed care facilities who refer to you.




In person
Direct Mail
Business newsletter
Use the information in your community
speeches.
What Hearing Instrument Features lead to
Enhanced Consumer Satisfaction/Benefit?
 Signal
processing strategies
 Directional instruments
 Consumer control of the instrument (VC)
 Innovations in transducers
 Cerumen management systems
 Shell technologies
General Technique

Establish satisfaction & benefit norms

Measure satisfaction & benefit across
technologies

Compare each technology to norm group
(MarkeTrak)

Determine generic hearing instrument features
which lead to end-user success
Analog Programmable Hearing
Instrument Omnibus Survey

Ten manufacturers

13 technology samples

All survey respondents (U.S.)

Instruments



MarkeTrak Satisfaction Survey
Abbreviated Profile of Hearing Aid Benefit
Average sample size 368 (nearly 5,000 subjects)
Typical Usage Satisfaction by
Generic Feature
(Composite score: overall, value, sound quality, 1-on-1, reliability, perceived benefit)
N.S.
Multi-environmental Value
Satisfaction by Generic Feature
(Composite score: 9 listening situations, noise, directionality)
N.S.
N.S.
Total Subjective Benefit by
Generic Feature
(Composite APHAB score: EC, BN, RV)
N.S.
N.S.
Satisfaction by Technology on
Overall Satisfaction
64
69
Overall
76
79
90
78
78
Improves hearing
83
87
95
Type of hearing aid
MarkeTrak (Average)
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
WDRC - CIC
Percent satisfied
Single Channel/Memory Prog.
Multiple Memory/Channel Prog.
Multiple Memory/Microphone Prog.
Satisfaction by Technology on Sound
Quality
61
62
67
Sound quality
74
83
56
63
66
70
74
Natural sounding
40
61
47
Whistling/feedback
61
Type of hearing aid
65
MarkeTrak (Average)
WDRC - CIC
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
Single Channel/Memory Prog.
Percent satisfied
Multiple Memory/Channel Prog.
Multiple Memory/Microphone Prog.
Satisfaction in Difficult Listening
Situations by Technology
56
69
61
61
67
Place of worship
56
71
61
66
67
Outdoors
Car
Type of hearing aid
MarkeTrak (Average)
WDRC - CIC
0
10
20
Single Channel/Memory Prog.
Multiple Memory/Channel Prog.
Multiple Memory/Microphone Prog.
55
54
54
57
67
30
40
50
60
Percent satisfied
70
80
90
100
Satisfaction in Difficult Listening
Situations by Technology
45
49
45
42
Restaurant
67
34
58
40
43
45
Telephone
Type of hearing aid
MarkeTrak (Average)
WDRC - CIC
Single Channel/Memory Prog.
Multiple Memory/Channel Prog.
Multiple Memory/Microphone Prog.
26
34
26
27
Large Group
51
0
10
20
30
40
50
60
Percent satisfied
70
80
90
100
Conclusions

High-performance programmable analog
instruments - outperform non-programmable
instrument on key factors:








Overall satisfaction
Likelihood of repurchase
Positive word-of-mouth
Quality of life
Value (even with higher price)
Reliability
Perceptions of benefit
More listening situations
Conclusions
 In
general the more advanced features the
better:





programmable
multiple compression channels
multiple memories, responses (stronger effect)
multiple microphones (strongest effect)
multiple signal processing strategies
Omni versus Directional
Hearing Instruments
MarkeTrak VI (October 2002 HR)
Customer Satisfaction Improvements of at Least 15% Due to
Dual-microphone (Directional) Technology
(H.I. < 6 years of age)
Summary of Impact of Directional
Microphones on Customer Satisfaction
Omni-directional
programmable vs
non-programmable
Overall satisfaction
Directional (dual
mic) vs omnidirectional
7%
17%
Factors - 20% improvement
0
3
Factors - 15% improvement
0
17
Factors - 10% improvement
2
33
Top 10 factor improvement
5
10
Net listening situations imp.
6
12
Net perf/value factors imp.
8
11
Net total differences
27
42
Digital Hearing Instrument Study

Multiple manufacturer products were studied.
 Results of first large-scale study on satisfaction
with DSP hearing aids:






Single European based manufacturer
200 single mic
296 multiple mic
Compared to 418 MarkeTrak (analog) norms
Average age of instruments 7-8 months
Consumer completed MarkeTrak survey

45 ratings of hearing aid and dispenser
Significant Differences
Overall, Consumer Behavior & Dispenser
Factor
Overall
satisfaction
Quality of life
Recommend HA
Recommend HHP
Repurchase HA
Wear hearing aid
Dispenser service
Single Mic
& MarkeTrak




Multiple Mic & Multiple mic
MarkeTrak
& Single Mic










Significant Differences
Product Features
Factor
Single Mic
& MarkeTrak
Fit/comfort

Ease VC adjust.

Visibility
Packaging
Freq. Cleaning
Warranty
Ease Battery Chg.
On-going expense
Multiple Mic & Multiple mic
MarkeTrak
& Single Mic




Factor in yellow denotes top ten correlate of overall satisfaction.

Consumer Need for a Volume Control
Yes
35%
Yes
28%
No
46%
No
40%
Not sure
25%
Not sure
26%
Single Microphone
Multiple Microphone
Customer Satisfaction is related to
Need for a VC
% Overall satisfaction
100
Desire for Volum e Control?
Yes
Not sure
No
93
81
79
80
57
60
60
42
40
20
0
Single
Multiple
Number of Microphones
Significant Differences
Performance Factors
Factor
Single Mic
& MarkeTrak
Benefit
Reliability
Sound clarity
Natural sounding

Sound of voice
Soft sounds
Loud sounds
Whistling/feedback
Multiple Mic &
MarkeTrak
Multiple mic &
Single Mic








Factor in yellow denotes top ten correlate of overall satisfaction.
Significant Differences
Performance Factors (Cont.)
Factor
Single Mic
& MarkeTrak
Multiple Mic
& MarkeTrak
Value
(price/perf.)
Directionality
Use in Noisy Sit.
Battery Life


Multiple mic
& Single Mic
 


Factor in yellow denotes top ten correlate of overall satisfaction.
Significant Differences
Listening Situations
Factor
One-on-one
T.V.
Small Groups
Listening to
music
Place of worship
Outdoors
Leisure activities
Single Mic
& MarkeTrak
Multiple Mic
& MarkeTrak
Multiple mic
& Single Mic



Factor in yellow denotes top ten correlate of overall satisfaction.

Significant Differences
Listening Situations (Cont.)
Factor
Car
Restaurant
Concert/movie
Workplace
Telephone
Large group
Single Mic
& MarkeTrak
Multiple Mic
& MarkeTrak

Multiple mic
& Single Mic





Factor in yellow denotes top ten correlate of overall satisfaction.
Summary of Key Findings
Single Mic
DSP
Multiple
Mic DSP
+3%
+17%
Factors with 10%+ improvement
(vs. MarkeTrak)
4
14
Top ten consumer factors improved
(vs. MarkeTrak)
0
6
Net listening situations improved
(vs. MarkeTrak)
-1
4
Net performance/value factors
improved (vs. MarkeTrak)
-2
6
Significant differences
(single vs. multiple microphone
DSP)
1
14
Overall customer satisfaction
improvement (vs. MarkeTrak)
Conclusions
 Performance




in noise:
Key reason why hearing-impaired do not buy
hearing aids (MarkeTrak).
#1 hearing aid improvement sought by
hearing aid users (United States)
#1 hearing aid improvement sought by
hearing aid users (German study).
#2 reason why our customers place their
hearing aids in the drawer (MarkeTrak).
Conclusions
 Consumer
studies now demonstrate the
superiority of multiple microphone
hearing aids over omni-directional only
aids.
 Customer satisfaction with directional
hearing instruments equal to consumer
electronics : 81%.
 Consumer research supportive of
dozens of small clinic/lab studies or
theoretical papers.
Conclusions

Performance in noise:
 Key reason why hearing-impaired do not
buy hearing aids (MarkeTrak).



#1 hearing aid improvement sought by
hearing aid users (United States)
#1 hearing aid improvement sought by
hearing aid users (German study).
#2 reason why 907,000 of our customers
placed their hearing aids in the drawer
(MarkeTrak V).
Recommendations

Fit all qualified candidates with directional
hearing aids (BTE, Full concha, half shell).

If not available, ask manufacturers to extend
directional feature to lower priced product (not
just high end programmable.)
Recommendations

Make sure your patient can live without VC or
directional/omni-directional switch.



Completely automatic aids are tremendous feature for
some, but not all, consumers.
Lack of control could dramatically impact satisfaction
especially for experienced user.
Independent research shows 77% of consumer WANT
a volume control.
Recent Research with MicroWaxbuster
Demonstrates it Will Dramatically Reduce
Hearing Aid Service Rates
MicroWaxbuster Cutaway
CIC with MicroWaxbuster
installed
Receiver Replacement Index
7,000,000 small receiver study at Knowles : receiver
replacements are 8 times less likely if the manufacturer
was a heavy user of the Waxbuster or MicroWaxbuster than
if they used none.
100
90
80
70
60
50
40
30
20
10
0
100
88
66
60
48
18
None
1-9%
10-19% 20-29% 30-49% 50-69%
Waxbuster/MicroWaxbuster Usage
13
70%+
Study # 2 – 90,000+ Consumers
 Database
query of one US manufacturer.
 24 month study across three styles of
hearing instruments: CIC, ITC, ITE.
 Consumers segmented:


Age of instrument – 1-24 months
MicroWaxbuster usage or None.
 Tracked
receiver replacements in
corporate service files.
Receiver replacement rates per 100 CIC
hearing aids (n=21,345)
Receiver Replacement Rate
45
40
35
30
MicroWaxbuster
No Wax Guard
Poly. (No Wax Guard)
Poly. (MicroWaxbuster)
25
20
15
10
5
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Age of Hearing Aid (Months)
Receiver replacement rates per 100 ITC
hearing aids (n=47,316)
Receiver Replacement Rates
30
25
MicroWaxbuster
No Wax Guard
Poly. (No Wax Guard)
20
Poly. (MicroWaxbuster)
15
10
5
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Age of Hearing Aid (Months)
Receiver replacement rates per 100 ITE
hearing aids (n=21,647)
30
Receiver Replacement Rates
MicroWaxbuster
25
No Wax Guard
20
Poly. (MicroWaxbuster)
Poly. (No Wax Guard)
15
10
5
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Age of Hearing Aid
15
16
17
18
19
20
21
22
23
24
Conclusions




Increased use of cerumen management products will
have a positive impact on the market place.
Offer this as a strongly recommended option to your
patients/customers.
Both manufacturers and dispensers should recognize
increased profits by selling this optional component
while reducing within-warranty repairs.
Consumers for a small additional fee, will experience:
 Greater reliability in their product,
 Resulting in fewer hearing instrument repairs,
 Reduced frustration and therefore,
 Increased consumer satisfaction.
Shell Technology
 1960's
industry adopted dental industry
approach - acrylic shell.





Hardness factor of 90 point Durometer Shore D
Little changes since development
More of a serious problem with ITC/CIC and aids
deeply inserted in the bony portion of the ear.
Difficult to achieve good acoustic seal with jaw
motion.
Internal mechanical feedback pathways
Soft Shell Technology
 Improved
fit & comfort
 Improved
fit with torturous ear canals
 Other


potential benefits:
> gain before feedback
< displacement of hearing aid
Technology is Only as Good as the
Weakest Link
 Shell
technology
 Advanced
fitting protocols that assure
optimization of benefit for the consumer
versus default settings
 Impressionless
hearing aids (3-D digital
models of the ear canal)
Systematic Feedback From the End User is a
Key to Improvement

Subjective and objective satisfaction/benefit
measures from the end user:





Compare a technology to a norm
Compare technologies
Measure change over time
Evaluate outcomes in different "real life" situations
Document reduction in disability




Potential importance for third party payment
Improving physician referrals
Shaping consumer expectations
Trouble shoot unsuccessful fittings
Systematic Feedback From the End user is a
Key to Improvement
Can we move forward into the
future without comprehending
where we are or where we have
been?
MarkeTrak Customer
Satisfaction Norms

Available since 1991.
 National Family Opinion Panel



Screening survey (80,000 households)
Hearing difficulty
Hearing aid owners

Identified 13,000 + households with at least one
person with hearing difficulty
 Detailed surveys



3,000 hearing aid owners
3,500 non-owners with hearing difficulty
80%+ response rate
MarkeTrak Customer Satisfaction
Norms
 Hearing


aid owners
41 Likert scale items on satisfaction with
hearing aids & service
5 Behavioral items (repurchase, hours aid
worn, quality of life)
MarkeTrak Norms:
Select Customer Satisfaction Factors
MarkeTrak Norms:
Customer Satisfaction in Select Listening
Situations
Percent of Consumers Receiving Follow-up
Customer Satisfaction Survey
(H.I. < 6 years compared to H.I. <1 year in age).
Post-survey method
58.9
57.2
None
21.1
21.5
Verbal office
9
8.7
Mail
5.3
7.1
Written office
4.1
2.6
Phone
1.7
3
Computer office
0
5
Age of H.I.
H.I.< 6 years
H.I.< 1 year
10 15 20 25 30 35 40 45 50 55 60 65 70
Percent hearing instrument owners
Overall Satisfaction Improves with Post-fitting Survey
Follow-up
(H.I. < 6 years compared to HI < 2 years).
Post-survey method
Age of H.I.
< 6 years
< 2 years
54
None
57
62
Verbal office
60
68
Mail
71
69
Written office
72
64
Phone
69
62
61
Computer office
30
40
50
60
70
Percent overall customer satisfaction
80
Recommendations

Pre-post benefit on EVERY patient:



Subjective test : APHAB or HHIE
Objective test : HINT, QuickSIN (Etymotic)
Customer Satisfaction survey at least 90 days
after fitting.



Shows you care
Permits insights when tied to patient information
Damage control of practice
Some Final Considerations
 Measuring
performance helps drive
success.
 Without
effective measurement how can
we assure we have optimized the
customer’s hearing experience?
 Without
effective measurement how can
dispenser’s grow in their wisdom on behalf
of the consumer?
From:
Evidence for the Binaural
Advantage Using Customer
Satisfaction & Benefit Data.
(Kochkin, Kuk 4/1997)
U.S. Binaural Hearing Instrument Owner
Population Trend
80
Total Owners
74
74
70
% of Hearing Instrument Owners
70
65
Total Owners - Current year
61
65
64
60
60
51
52
47
50
37
40
30
22
25
20
10
0
1984
1989
1991
1994
1997
2000
2004
Why Such Remarkable Binaural
Growth in U.S.?

Paradigm shift in mid 80's by industry and
hearing professionals.



"Two ears are better than one" (therefore two hearing
aids)
Based on clinical & field studies
Hearing professional education


Consumer education
Marketing
 brochures
 posters
 public relations
Basic Reasons for Fitting Binaurally










Sound localization
Threshold for speech reception
Group & noisy situations
Head shadow effect
Loudness summation
Auditory deprivation
Litigation (malpractice)
Balanced hearing
Sound quality
Customer satisfaction & subjective benefit
Knowles Binaural Satisfaction
Study
2


samples of bilateral loss subjects
MarkeTrak - (n=1,124)
High performance hearing aids - (n=3,279)
 Compare
binaural and monaural
satisfaction/benefit results.
 Difference
scores on key factors.
Satisfaction with Directionality of Hearing Aid for 5 Samples of
Bilateral Loss Subjects Fit Either Monaurally or Binaurally.
Monaural vs. Binaural Customer
Satisfaction (Key factors impacted)
Conclusions

Binaural advantage




Strong binaural advantage independent of
technology.
High performance product show stronger binaural
effect.
Directionality, sound quality & some listening
situations
Remainder of world is behind US in binaural
penetration:


Europe -30-45%
Japan - 10%
Actions

Fit all qualified customers binaurally. (e.g.
symmetrical loss)

Use aggressive binaural selling protocol to
demonstrate IMPORTANCE of binaural hearing:





Demonstrations with education
Master hearing aids
During audiological testing
Try 2..if you don't like return one.
Binaural tutorial and consumer selling points
(English and Spanish):

www.betterhearing.org (market research section).
Actions
 Binaural

Selling Protocol (cont.):
Request signed legal form :
indemnifying you against legal action
because of consumer refusal to follow your
advice
consumer understands potential for
"auditory deprivation" in unaided ear.
consumer understands 15 reasons why 2
hearing aids are better than one.
Actions
 Binaural

Selling Protocol (cont.):
Refuse to sell monaurally.
Truly impressive --- shows you have strong
convictions.


Use the words "hearing system" not hearing
aid.
Give discount on hearing system.
Customer Requirements –
5 dimensions

Reliability - the ability to provide what was
promised.

Responsiveness - the willingness to help
customers promptly.

Assurance - the knowledge and courtesy you
show to customer; ability to convey trust,
competence and confidence.
Customer Requirements –
5 dimensions
 Empathy
- the degree of caring and
individual attention you show to your
customers.
 Tangibles
- the physical facilities and
equipment and your appearance.
Some Suggestions

Complete customer service workshops


audiologists/dispensers
office staff – receptionist

Handling inquiries, handling leads, effective
selling, customer relations
 How to handle the difficult customer
 What to do when mistakes are made
 AAA "best practices" training - great promise


Reception training kit
Physician referral – also through BHI.
An excellent
starting point for
your whole staff.
Highlights
















Adjusting to the customer
Uniqueness of each customer
Selling skills
Your attitude & success
Importance of self-esteem
Phone relations
Effective listening
4 minutes to make an
impression
Games customers play
Angry customer
Negotiation
Becoming creative
Your image
Handling stress
Handling change
Customer rights
Amount of Counseling Time Spent with Hearing Aid Users During
Last Hearing Instrument Purchase
(H.I. < 6 years compared to H.I. < 1 year).
35
Modal time is half hour
Percent of users
H. I. User
New < 6 years
Experienced < 6 years
All <1 year
30
25
None
0.25
0.5
0.75
4.3
3.4
4.3
0
3.3
2.2
2.2
5
4.4
4.6
5.7
13
14.4
12.8
10
18.3
19.8
20.7
15
25.1
24.3
25.2
31.7
31.4
29.2
20
2
3+
1
Counseling time spent (hours) with users
Customer Satisfaction Ratings are Related to Time
Spent in Counseling
(H.I. < 6 years compared to H.I. < 1 year).
80
60
50
60
68
65
65
68
67
0.75
1
2
65
59
59
64
62
0.5
53
54
63
59
20
42
30
52
48
40
39
45
42
Percent of users
70
H. I. User
New < 6 years
Experienced < 6 years
All <1 year
10
0
None
0.25
Counseling time spent (hours)
3+
Consumer Education Can Reduce
Returns

31 dispenser study
 289 subjects - all new patients randomly
assigned:


Half received normal counseling
Half also received Dr. Richard Carmen's
Consumer Handbook on Hearing Loss

Dispenser prescribed 3 chapters to read
before end of 30 day trial followed by
discussion.
 Return rates were as follows:


16.3% control group (no book)
8.8% subjects receiving book
Counseling Training

Counseling skills need to be upgraded
 Certification program



Video training
Adjunct degree - MS in counseling
Recommendation - Rogerian Counseling

Au.D. to have value perhaps should have more
counseling

Post fitting group - key to returns
www.knowleselectronics.com
Recommended
Readings:
J. Abrahamson - post
fitting group
sessions.
C. Palmer & E. Mormer
- Systematic
counseling protocol
C. Edwards - pediatric
population
You are Only as Good as the Weakest
Link in Your Community

U.S. Industry plagued by negative publicity







Ralph Nader
60 minutes - ripping off elderly
FDA/FTC
Rip-off Alert - 7 new scams (Family Circle 6/24/97)
Hearing aids don't work articles
Recent Washington Post article on taking advantage
of the elderly --- and not allowing returns when
dissatisfied.
You are judged by the competence of your
competitor down the street.
Current Nonowner Attitudes Toward U.S.
Hearing Health Distribution Channels
Attitude
Trust in doctors
12.2
Trust in audiologists
12.1
38.3
49.6
51.5
36.4
Trust in HA dealers
39.7
HA sellers customer oriented
37.9
49.1
13.1
HA sellers take advantage
37.6
48.3
14.2
Exposure to TV ads
10.6
Truth in advertising
30 day trial knowledge
Negative
Attitude
Neutral
17.7
7.5
7
71.6
30.3
0%
Positive
53.4
58.5
11.1
80.3
20%
40%
12.2
60%
Percent
80%
100%
“People buy from people...
people they like, they trust, they
respect; no one buys from an
enemy."
Sales Manager - Dupont
You are Only as Good as the Weakest
Link in Your Community
 Continued
need to upgrade educational
standards
 Standardize state requirements
 Industry must be own watch dog perhaps have ethics board
 Encourage sharing of techniques which
improve customer satisfaction:


industry award ceremonies
recognition
Comprehensive Fitting Protocols





Move toward an industry standard for fitting
hearing aids
From first contact to post fitting
Equivalent of industry recognized ISO 9002
Large public chains moving toward such a
standards.
Will probably be needed for managed care
relationships.
Comprehensive Fitting Protocols
 Models
of hearing aid success
needed:

Matching technology with consumer
hearing loss characteristics at the
point of sale.
Basic Recommendations











Pre-fitting counseling and needs assessment.
Objective measurement of hearing loss.
Establishment of contract with consumer.
Hearing aid validation using real ear.
Use of hearing aid analyzer (verification that HA
meets specifications).
Patient interaction to optimize fitting.
Objective & subjective measure of benefit.
Documentation of benefit to consumer and perhaps
physician.
Expectations relative to benefit.
Post fitting customer satisfaction survey.
Basic aural rehabilitation
Sample Protocol
Washington University School of Medicine

Established appropriate prescriptive REIG (corrected
for mixed HL (>20% of A-B gap) and/or binaural
summation (<3-5 dB))

REM for nonlinear hearing aids with input levels of
50, 65 and 80 dB with speech-weighted composite
noise (analog) or modulated ANSI noise (DSP)
provides appropriate gain and smooth frequency
response. Printout placed in chart.

REM for linear hearing aid with input level of 65 dB
with speech-weighted composite noise (analog) or
modulated ANSI noise (DSP) provides appropriate
gain and smooth frequency response. Printout placed
in chart.
Sample Protocol
Washington University School of Medicine

Assessed performance of directional microphone by
looking @ differences in REAR @ 00 and at azimuth of
greatest null. Printout placed in chart.

Assess functionality of DSP NR circuitry using
appropriate bias signals.

RESR90 using a pure-tone sweep corresponds to
appropriate frequency-specific SPL level for loudness
judgment of “loud, but OK.” Printout placed in chart.

Loudness judgment of 50 dB composite noise is “very
soft” or “soft”
Sample Protocol
Washington University School of Medicine

Loudness judgment of 65 dB composite noise is
“Comfortable, but slightly soft,” “comfortable,” or
“Comfortable, but slightly loud.”

Loudness judgment of 85 dB composite noise is “loud,
but OK.”

Measure aided thresholds @ 500, 1000, 2000 and 4000
Hz using FM signals @ 00*

Measure unaided and aided HINT (dBA) in Quiet with
sentences @ 00*
* Currently under consideration
Sample Protocol
Washington University School of Medicine

Measure unaided and aided HINT RTS in Noise with
Sentences and Noise @ 00*

ANSI-96 reveals <10% THD; ANSI-92 reveals smooth
coupler response @ 50-80 dB SPL. Printout placed in
chart.

Potentiometer or programmed settings are in the chart.

Discuss and/or recommended Aural Rehabilitation
and/or ALDs.
* Currently under consideration
Sample Protocol
Washington University School of Medicine
 APHAB, COSI or Wash U Questionnaire (unaided, aided
and benefit) and placed in chart.

Called patient 2-3 days post-initial fit.

Customer satisfaction survey (3-6 months after fitting) –
Kochkin recommendation.
Best Practices Discussion
Items
Benefit is Critical to Market Growth
 High


benefit is related to:
High customer satisfaction
High brand retention
 High


customer satisfaction :
Leads to positive-word-of-mouth
advertising
And therefore market growth
Benefit is Critical to Market Growth
 Important
to focus on the dispenser’s role
in optimizing consumer benefit.
 Current
consumer benefit is 44% HL
problem resolution in U.S. How can we
improve to 65% benefit in 5 years?
Selection/verification/validation
Some Considerations

Convene committee of industry’s brightest to
develop/recommend “best practices” hearing
instrument selection/verification/validation
protocol




Medwetsky found wide variability in protocols in 60
practices.
“might be a great need for a best practices standard
that is widely accepted and used by all hearing care
professionals”.
Standards may be available but not utilized (e.g.
ASHA guidelines for hearing aid fitting for adults)
Washington University School of Medicine Protocol
(attached for your review and consideration)
Selection/verification/validation
Some Considerations

Fitting formula have become more sophisticated
but they are still a starting point. How many
dispensers use the default settings versus
attempt to optimize individual benefit at the point
of sale?

There will be significant differences in outcome
measures both in terms of speech intelligibility
and subjective consumer preference depending
on which prescriptive formula is used. (See
January 2003 Hearing Review)
Selection/verification/validation
Some Considerations

May be significant interactions between
prescriptive formula, individual hearing loss
characteristics, style/circuit of hearing
instrument, and perhaps even the personality
of the end-user.

Advanced multivariate research (e.g. use of
artificial intelligence software) could lead to
the development of a prescriptive decision
tree which would assist the hearing care
professional in optimizing benefit for the enduser.
Selection/verification/validation
Some Considerations
 Does
the lack of wide scale adoption
and/or usage of real ear measurement
impact benefit?
 50% of HIS own
 75% of audiologists own
Selection/verification/validation
Some Considerations
 Does
the lack of wide scale adoption
and/or usage of hearing aid analyzers
impact benefit (e.g. measurements on
the functionality of the hearing
instrument). Is a listening test enough?
 59% of HIS own
 85% of audiologists own
Selection/verification/validation
Some Considerations
 Assure
audibility of important sounds
(especially speech) and loud sounds
should be comfortable:

44% satisfaction with loud sounds comfortable in a
custom industry is unacceptable.
 How
does a consumer leave a dispenser’s
office with hearing aids that are too loud?
Selection/verification/validation
Some Considerations

Measurement of unaided and aided speech
intelligibility in quiet and noise. The difference
is benefit (see January 2003 Hearing Journal):
 Why do the minority of dispensers and
audiologists measure benefit routinely?
 Subjective (APHAB), or objective (HINT,
QuickSIN) tests widely available.
 Share benefit scores :


with consumers helping to shape realistic
expectations.
with physicians to build your practice.
Selection/verification/validation
Some Considerations
 Does
the use of patient focused 360
sound field aided testing have a positive
impact on maximizing individual
benefit?
 Preliminary research shows < fitting
time
 No impact on APHAB benefit scores
 Possible significant impact on return
rates.
Selection/verification/validation
Some Considerations
 Should
we establish contracts with
consumers promising certain levels of
benefit in quiet and noise based on our
knowledge of the consumer’s hearing loss
characteristics?
 Should
consumers be made to pay for
hearing instruments with little or no
measurable benefit? (e.g. speech
intelligibility improvement).
Selection/verification/validation
Some Considerations

Measurement of longer term customer
satisfaction (3+ months after fitting).
 Minority- 18% do any form of formal
follow-up.

Issue of value assures that the
consumer expenditure of energy (time,
money) is exceeded by the dispensers
Dispenser
energy expenditure (time, service,
product).
Consumer
Selection/verification/validation
Some Considerations

Industry associations should validate the best
practices in order to gain wide scale
acceptance of a “golden” or “best practice”
protocol:
 Customer satisfaction
 Consumer benefit
 Profitability
 Dispenser morale
 Practice growth
 Referrals
 Return rates
Selection/verification/validation
Some Considerations
 Turn
best practices protocol into
equivalent “Good Housekeeping Seal of
Approval”. Implicit in such a seal is a
“benefit guarantee” to the consumer.
 Should
hearing aid dispensing outlets
earn such a “best practices seal of
approval” through an independent
audit?

Similar to ISO 9002 quality certification
Best Practices
 What
best practices methods have you
found which?
 Improve customer benefit
 Improve customer satisfaction
 Reduce return rates
 Best practice methods:
 Verifying hearing aid performance
 Validating hearing aid benefit
 Setting expectations
 Patient counseling
Some Methods for Improving
Satisfaction 10%-20%







More counseling time with consumer.
Creating realistic expectations especially given
very high consumer expectations of DSP.
Any form of outcome measure (benefit).
Use of VC especially for experienced user.
Directional hearing aids as standard technique
for improved communication in noisy situations.
More patient focused techniques for optimizing
benefit.
Creating more perceived value for the
consumer.
Value
Dispenser
Consumer
 The
secret to success (customer bliss)
is value:


Energy expenditure from dispenser
(product, time, service) must exceed
consumer's expenditure (money, time)
 Satisfaction
= balanced expenditure.
Value

Key factors to end-user when evaluating HA
outcome:

Perception of benefit

Multiple environmental listening utility (MELU)
 Performance in noise
 Not just one-on-one in quiet

Sound quality

Reliability
What is Value?
 Service
provided + performance of hearing
instrument (benefit)
 Relative
to how much was paid for the
product & service
What is value?
Value
Value ==
Price
Price of
of hearing
hearing
aids/service
aids/service
--------------------------------------------------------Benefit
Benefit == need
need fulfillment
fulfillment
Benefit
Benefit APHAB=
APHAB= Unaided
Unaided -- aided
aided
------------------------------------------Unaided
Unaided
== %
% reduction
reduction in
in disability.
disability.
=$$
=$$ paid
paid per
per %
% disability
disability reduction.
reduction.
Satisfaction
Customer Satisfaction is Highly Related to $$$
Spent per 1% Improvement in Hearing Disability
100
95
90
85
80
75
70
65
60
55
50
45
40
35
30
25
Overall
Benefit
Value
Poly. (Overall)
Poly. (Benefit)
Poly. (Value)
5
15
25
35
45
55
65
75
85
95
125
Price ($$) spent per 1% disability improvement
200
500
Overall Customer Satisfaction as a Function of Price
and Hearing Disability Improvement
(Statistical Model)
Overall
Customer
Satisfaction (%)
Price
Hearing disability
improvement (%)
R2=.86
Hypothetical Situations - Value
Handicap
Reduction
Price
Value
Comments
-25
1000
-40
Consumer's
hearing got
worse & lost
money
10
500
50
Low benefit at
low price
100
5000
50
Great benefit
at a high price
Satisfaction is Related to the Age of
the Hearing Instrument
70
Satisfaction
60
50
40
30
20
10
0
<1
1
2-5
6-9
Age of Instruments
10-14
15+
…and to Hearing Aids in the Drawer
35
% in drawer
30
25
20
15
10
5
0
1
2
3
4
5
6
7
8
Age of Hearing Instruments
9
1014
15+
Recommendations

Maintain contact with past consumers.
 Develop marketing and incentive programs to
assure that technology in consumer’s ears is < 5
years old.
 Friends of consumers will judge newer
technology based on consumer’s perceptions of
10 year old technology.
 Critical to work with consumers to keep hearing
instruments out of the drawer.
A Word About Expectations
 Expectations
are critical when you
serve customers.
 Meet
them to satisfy the customer.
 Exceed
then to make the customer
love you.
A Word About Expectations
 Set
unrealistic expectations--in
essence,
 promises
you can never hope to keep--
then:
 your
customers will hold you beneath
contempt.
Expectations

Model expectations protocol is needed




Written form
Video (role play)
"Best practices"
Basic primers on expectations


High Performance Hearing Solutions - Vol 1.
Counseling.Realistic Expectations - A Key to Success
(P. Stypulkowski) – www.knowleselectronics.com
Rose Allen – www.audiologyonline.com 5/20/02
What Can You do to Move
From Customer Satisfaction
to Customer Bliss in Your
Practice?
Personalize

Choose one or two areas and work on them in
your practice.
 Find out what your customers think about you!



Formal survey
Breakfast chat with customers
Question or evaluate everything you do & were
taught to do in fitting hearing aids.
 Encourage employees to recommend
improvements.
 Reward suggestions & improvements.
Personalize
 Add
to my list of ways of improving
satisfaction:





Test equipment
Methods of testing
Paradigms on candidacy
Fitting algorithms
Methods of optimizing fitting (e.g. use of 360
degree sound field)
Our Role is To Assure the
Customer’s Life is Improved by
Our Product & Service

Assure that your clients have achieved
significant benefit with their hearing aids.
 Assure that your customer is satisfied with
their hearing instruments.
 Three areas of possible improvement:



Minimize hearing aids in the drawer.
Use technology and processes which enhance
increased customer satisfaction.
Basic best practices