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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