Quality is about execution of techniques and processes
In today’s competitive market, hearing instrument technology no longer differentiates one practice from another. All dispensing professionals have access to roughly the same hearing aid technology, if not the same products. Moreover, we all have access to the same test equipment and the same techniques and processes for serving our patients. Additionally, the Internet now makes available the majority of hearing care products to the masses with or without our individualized services. Given these facts, one can make the argument that hearing aids, and the business of providing hearing healthcare, are largely commodities.

Saying we are in a commodity business, while sounding crass to some, should come as no surprise, and should be not construed to mean that hearing aids are somehow ineffective. Many of the features that significantly benefit our patients—like automatic feedback suppression, occlusion effect managers, and adaptive directional microphones to name a few—have been fully realized in the digital era and almost assuredly will continue to improve over time. Although they call them different things, with some exceptions, all hearing aid manufacturers offer the dispensing professional, and the end user, the same digital technology. The fact that technology is becoming increasingly a commodity is happening throughout the entire healthcare industry. The challenge is trying to separate yourself and your practice from the competition without relying on technology.

Perhaps an example from another health-related industry will help illustrate this point. Cystic fibrosis is a genetic disease. It is also terminal. The effects of the disease on the lungs are what make it lethal. However, with proper rehabilitation, both quality of life and overall life expectancy can be significantly improved. Physicians and nurses who care for patients with cystic fibrosis around the country have a regimented and detailed clinical protocol they must follow if they are to be reimbursed by insurance companies. From a business perspective, you can think of the staff and clinical protocols as commodities: all the professionals have the same training and licensing requirements, and they adhere to a strict non-negotiable procedure using the same equipment.

Interestingly enough, there is one clinic, despite this level playing field, that outshines all others around the country when it comes to life expectancy and improved quality of life. Year in and year out, this clinic located in Minnesota outperforms all others on these two critical variables. This interesting feat got the attention of a medical writer who investigated why this occurred.1 What he found was the staff at this facility held their patients accountable to following their rehabilitation exercises and other therapy procedures in a more rigorous fashion than other cystic fibrosis centers around the country. It is not uncommon for the staff of this hospital to send someone home early from an appointment after a stern lecture, imploring them to not skip any steps of the rehabilitation process and return in another week after “they have got it right.” Besides a lesson on the importance of patients following their aural rehabilitation programs, the take-home message for the hearing healthcare provider is how this facility transcended the commodization of their business by having an obsession with quality.

So, the question remains, how can one separate his/her practice from the competition in what is arguably (for the consumer) a commodity business? The one factor that can distinguish your practice from that of the competition is an obsession with quality.

Quality is about execution of these techniques and processes. Quality is about leadership, innovation, and inspiring your employees and co-workers to be the best. Focusing on three separate and distinct dimensions of quality goes beyond mere units sold and forces us to provide a memorable and engaging experience with every patient.

The Three Dimensions of Quality
1. Culture.
Many practices still subscribe to the outworn management doctrine that leadership is about conveying ideas from the bosses head to the employees’ hands. Innovative practices, on the other hand, are actively engaged in building management capital through quality at all levels.2 They have developed metrics to regularly assess quality and value. The innovative business then uses these metrics to improve processes, tools and strategies as they relate to the patient. Furthermore, the practice focusing on quality fosters an environment allowing professionals to act, learn, and make decisions about how to provide superior value to patients. The use of a comment card—finding out what patients think about your practice—is an effective way to see if your message is getting across.

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FIGURE 1. A comment card gives patients the ability to provide feedback and dispensing professionals the ability to assess their performance relative to patient satisfaction and benefit.

Figure 1 is an example of a comment card used in several hearing aid dispensing practices around the country. This eight-question card is designed to quantify all facets of the patient’s experience in your office. The use of this comment card is based largely on the work of the Bain Group in Boston who have been systematically studying customer satisfaction in various service-oriented businesses for several years.

According to the Bain Group, the question “How willing are you to recommend a family member or friend to this office?” is the only question on a comment card that correlates customer satisfaction with office profitability.3 All patients scoring a 6 or less on this question are considered to be “detractors” of your office. That is, they are not only dissatisfied, but are likely talking about their dissatisfaction with family, friends, and perhaps others with whom they come into contact.

One of the primary responsibilities of an effective manager is to communicate with these unhappy patients: find out what happened, and adjust your processes accordingly to ensure that other patients do not experience the same type of problem.

2. Process. One of the key ingredients of a successful professional is the consistent use of a clinical process or protocol. Although sometimes hard to define, “professionalism” is the leading reason customers choose to do business with their healthcare providers. The underpinnings of professionalism are the use of a disciplined, consistent, and non-negotiable process through all aspects of your business. Processes should be interwoven throughout your practice from the way your office staff answers the phone to the way you verify the performance of hearing aids. Let’s focus for a moment on the importance of using a hearing aid fitting protocol.

Right now there is no compelling evidence suggesting that any one particular clinical protocol is better than another. Several clinical practice guidelines have been recommended over the years by professional organizations and others for fitting hearing aids. However, there is little or no data to support any of these guidelines. There is, however, considerable indirect evidence supporting the fact that patients fit according to a particular protocol have positive real-world outcomes.4

As a manager of a hearing aid dispensing clinic, it would be imperative to implement some or all of these successful protocols into your own clinical process. Perhaps the most effective way to do this is to take this indirect evidence and weave it into your own non-negotiable standard. Figure 2 shows an example of a non-negotiable standard form. Once your clinic staff has been educated on the steps of your protocol and understands the “whys and hows” of each step, the next step is for the manager and the clinician to sign the non-negotiable standards document. This helps establish the importance of adhering to the standards you have termed “non-negotiable.”

FIGURE 2. The non-negotiable standards form that obligates staff to the established process.

3. Outcome—Validating Real-World Results. Health care systems are evolving that are increasingly consumer-driven. In this customer-centered system, it is the patient who largely decides what treatment option is selected. In this new era, the major index of quality is self-report outcomes and satisfaction data. This change in philosophy forces the hearing care professional to focus on the patient rather than the hearing aid or even the results of the audiogram. With today’s more savvy patient, what the clinician thinks may not matter very much if the client has a different opinion about his/her quality of care.

Self-report measurement tools like the International Outcome Inventory for Hearing Aids (IOI-HA) and Client-Oriented Scale of Improvement (COSI) need to become a systematic and universally accepted method of validating the results of each fitting. Not only do these tools provide a scientifically defensible way to measure real-world experiences with hearing aids, they allow the patient to see how much benefit they are receiving from recommended treatment options.

The IOI-HA is a practical way to measure both satisfaction and benefit with hearing aids.5 The seven-question IOI-HA should be given approximately two weeks after the initial fitting. Each question has five possible answers, and each of the five possible answers has a number that corresponds to it. The patient should be instructed to circle the answer that best reflects his/her experience with the current hearing aids. After the patient completes the IOI-HA, you simply add up the numbers for each of the answers to the seven questions. Based on clinical research, if your patient obtains a score of 22 or greater, they are receiving significant benefit and satisfaction for their hearing aids. This makes the test extremely easy to use, and it provides an excellent way to standardize your benefit/satisfaction measures.

The COSI is a test in which the clinician identifies important individual listening situations sited by the patient for improvement.6 These situations are identified at the initial patient visit. When the hearing rehabilitation program is “completed,” these listening situations are read back to the patient, and the patient indicates how well they can now hear in those situations. The test is scored and this data can help determine if, indeed, the rehabilitation program is sufficiently completed. Like the IOI-HA, normative data for the COSI exists, providing a scientific means for comparing the satisfaction/benefit scores.

Improving Quality: What You Can Do Today
According to small-business guru Michael E. Gerber,7 you need to clarify—both for yourself and for your staff—the story of your practice. Then you need to detail the process your practice must go through to make your story become reality. Gerber refers to this as the Business Development Process. Others call this “Total Quality Management” or TQM:

1. Innovation. Continue to find better ways of doing things. Make it your mission to inspire an attitude of continuous learning. We all can get better at something. Pick something and get busy improving it.

2. Quantification. One goal should be to provide the most memorable and complete service experience you can with every customer you encounter. You need to work with your front desk person to do this. The way you measure your progress is by looking at the numbers. One example is to systematically measure quality by asking your patients to complete a customer comment card.

3. Orchestration. Once you have discovered a better process in which to do something and quantified that this process will drive patient satisfaction, orchestrate this better way of running your business so that it becomes a standard you and your staff can repeat over and over again.

Brian Taylor, MA, is senior manager of the Professional Development Department
for Amplifon USA, Plymouth, Minn.

Correspondence can be addressed to Brian Taylor, MA, Amplifon USA, 5000 Cheshire Ln, Plymouth, MN 55446; email: [email protected].

1. Gawande A. The Bell Curve: What happens when patients found out how good their doctors really are? The New Yorker. 2004;December 6:25-30.
2. Feigenbaum AV, Feigenbaum DS. What quality means today. MIT Sloan Management Review. 2005;Winter.
3. Reichheld, Frederick. The one number you need to grow your business. Harvard Business Review. 2003;81(12):46-54.
4. Humes, L, Humes L. Factors affecting long-term hearing aid success. Seminars in Hearing. 2004;25(1):63-72.
5. Cox R, Alexander G, Beyer C. Norms for the international inventory for hearing aids. Intl Jour Audiol. 2003;14(8):403-413.
6. Dillon H. Assessing the outcomes of hearing rehabilitation. Hearing Aids. New York: Thieme: 349-369.
7. Gerber ME. The E Myth Physician. New York: Harper Business Press; 2003.