Does “The Customer Is Always Right” apply in Health Care?
December 11, 2013 from Donna Setterholm, as a staff nurse on a telemetry unit in St. Paul, MN
Dear (CEO’s name left out intentionally as permission to publish it has not been obtained),
I am concerned about the message we were given in your monthly communication dated December 6, 2013 at 10:58 in which you asserted that in healthcare, “the customer is always right.” Please consider the following research, thoughts, and balance we need in our efforts to make healthcare affordable and efficacious. To reduce recidivism, we must gain the customer’s partnership in promoting their health. That may not be what the customer wants, but that is the business we are funded to be in.
The message I received in the communication is, “the customer is always right.” Logically, if the customer is always right, and if there is a disagreement, challenge, or dispute, then the employee is always wrong. That premise is invalid in healthcare. The customer does not always know what is right for them and may even choose to be non-compliant after education is provided by a health professional or be addicted to a conflicting paradigm. Doctors and registered nurses are not trained nor educated to become enablers in customer dysfunction, nor should they be. A balanced model of healthcare delivery includes substantial emphasis on care provider competence and training. It is relatively easy to provide care for patients who are educable and compliant. It is difficult to provide and promote health with noncompliance; recidivism will be high with these patients. Many of us were trained to use “tough love” approaches with these patients. We need support from management, not criticism while we are trying to help customers take responsibility for their role in their own health care.
Recent case en pointe: Last week, I took care of a demanding, manipulative female who was morbidly obese; had been a diabetic for 10 years, and was admitted with congestive heart failure (CHF). She has been admitted many times due to her noncompliance. I believe that I took care of her the third day after this admission. That evening, she ate food from the time I came on at 1500 until 2200. It did not register with me at first where she was getting the food, because dietary would not send more than she was allowed on her diabetic diet. But at her evening meal, I had to give her 19 Units of regular insulin to cover her high blood sugar level. Then I gave her 100 units of Lantus at 2000. At bedtime, her blood sugar level was over 350, a level which required me to contact the physician per hyperglycemic protocol. I gave her 9 more units of regular insulin. That is a lot of insulin in a short period of time. At 2230, she asked us for more food – graham crackers – not just two packets, but 5 packets. I said, “No, your blood sugar levels are running too high. I cannot give you more food. The more food you eat, the more insulin you have to take. High doses of insulin can cause problems with your arteries – congestive heart failure.” She said, “Don’t you give me none of your lip, Miss Donna. I’ve been a diabetic for 10 years and I know how to take care of my diabetes.” I refused to give her more food. (Other nurses had been giving her what she wanted.) She complained to my manager about me – said it was “how I said it.” In reality, the patient did not like the message and yes, I was very firm with her because that was what she needed.
The next day, I took care of her again. When I initially went into the room, she immediately said with lots of “steam”, “I don’t want none of your lip today, Miss Donna.” I left the room without doing her assessment to think about how I was going to deal with this situation. I could have requested a change in assignment, but that would have been a “cop-out” in providing what she really needed. So, I returned to her and calmly said, “I think we have an understanding now. You want me to allow you to eat all the food you want and I’ll cover your blood sugar levels with all the insulin you need. I will no longer care for you or about you like I do for all my other patients; I will not try to educate you. So, I think we will get along just fine.” I left the room, not waiting for a response.
About 15 minutes later, I returned to do her assessments. Her “steam” was gone and she apologized and we had a therapeutic intervention. “You are right Miss Donna, I am out of control. I can’t stop eating.” She indicated she had been going to the gift shop and the vending machines for more food/candy. “I do need more education about diabetes. I was supposed to have gastric bypass surgery, but the surgeon has refused to do it until I get my diabetes under control. He said I wouldn’t make it through the surgery or recovery. I need help, but don’t know how to get it.”
I told her the first step was acknowledging she had a problem. The second step was to be open to receiving help, recognizing she might not like what she hears or what life style changes she needs to make. Surround yourself with people who will help you, not give in to your demands. Both food and insulin can be dangerous drugs for a diabetic. “Don’t fight us, work with us.”
Fortuitously, the chaplain arrived on the unit after I had this conversation with the patient, so I shared the issues with the chaplain. After the chaplain saw her, she told me that the patient essentially said the same thing to her and is asking for help. It did not stop this patient from asking for more graham crackers at 2330 when she thought I was off duty. (Over-eaters anonymous – Help – A day at a time.) Nor did my manager support me with her original complaint.
Nursing is not just a science, but a healing art. We need support in providing the interventions required to obtain the customers trust and cooperation. It is an ongoing fact that if a patient complains, the manager will often reprimand the employee. It is not the fault of the unit managers for doing so if they are told by top management that they must preserve “the customer is always right” philosophy. Many nurses will promote customer satisfaction in lieu of health promotion just to keep their jobs or receive decent evaluations. “Getting along” becomes the priority of care. Note: Job satisfaction is important, too.
My cousin, Robert Stollenwerk, who was president of Wisconsin SCORE and on the board at Cargill, told me that the customer is not always right; but if they have been wronged or have legitimate complaints, we must address their concerns. Often positive change occurs because consumers may have a better idea, but employees do not have to support dishonesty, theft, and physical, verbal or emotional harm. During this conversation, he was speaking about retail businesses, not healthcare.
I have included an article below on the history of “the customer is always right” motto/slogan. It was instituted at a time when we had no quality assurance programs, consumers’ reports, better business bureaus, or any recourse for consumers. The late 1800’s was a different time.
Source: Wikipedia – a common source utilized by the general public. Search words used: history of the customer is always right.
For other uses, see The customer is always right (disambiguation). Marshall Field used slogans such as “Give the lady what she wants” in his Chicago department store.
“The customer is always right” is a motto or slogan which exhorts service staff to give a high priority to customer satisfaction. It was popularized by pioneering and successful retailers such as Harry Gordon Selfridge, John Wanamaker and Marshall Field. They advocated that customer complaints should be treated seriously so that they should not feel cheated or deceived. This attitude was novel and influential when misrepresentation was rife and caveat emptor (let the buyer beware) was a common legal maxim.[1] Variations include “le client n’a jamais tort” (the customer is never wrong) which was the slogan of hotelier César Ritz[2] who said, “If a diner complains about a dish or the wine, immediately remove it and replace it, no questions asked.”.[3]
However it was pointed out as early as 1915 that there can be an issue with customer dishonesty and that a careful medium between the two extremes must be made.[4]
For other uses, see “The customer is always right (disambiguation)”.
There are many other articles written about this topic. I was unable to understand the chart from the Attorney General regarding patient complaints filed in your (the CEO’s) newsletter because the colors did not transfer well. However, I do know that not all complaints filed to the Attorney General are legitimate and some may be dismissed.
If we consistently provide excellent and appropriate care for our patients, taking into consideration what is the best course of action for each situation, we will have the reputation for achieving that excellence in an affordable way. Our reputation will not only be customer based, but professionally based. Attracting and retaining well known or highly competent professionals will be an automatic result.
Respectfully submitted,
Donna Setterholm, RN, BSN, MA in HHSA
cc: President of hospital, Unit manager, MNA Representative, & Human Resources at hospital