Article Date: 12/1/2009

Hard Lessons Learned About Patient Loyalty
patient loyalty

Hard Lessons Learned About Patient Loyalty

Don't be surprised when satisfied patients defect. Here's why.

BOB LEVOY, O.D., Roslyn, N. Y.

How do you keep patients loyal to your practice when would-be competitors turn to price-cutting, BOGO (buy one get one) and assorted special promotions to capture new patients? This is one of the many challenges facing optometrists in their quest to gain loyalty from disloyal patients.

It's no easy task. More and more patients consider themselves "healthcare consumers." These patients often have lofty expectations of your practice as they consider not only price but the complete patient experience — from scheduling an examination through every phase of the office visit to the products you recommend, prescribe and sell. If any step along the way fails to meet these expectations, the patient (and his family and friends) may go elsewhere.

Conversely, there are many benefits (beyond the obvious) of having loyal patients, including:

► Loyal patients by definition, have more trust in your recommendations and are more likely to accept them without "shopping around," seeking a second opinion or purchasing their contact lenses from a mail-order firm.
► Loyal patients tend to be more tolerant of minor problems, such as delays.
► Loyal patients are the most vocal, telling others about the quality of care and service they received.
► Revenue grows as a result of repeat visits and word-of-mouth referrals.
► Costs decline. Established patients require less paperwork and fewer explanations.
► Costs also decline as the need for advertising and practice promotion decrease. (It costs five times more to acquire a new patient than it does to retain an existing one).
► It can be argued that employee retention increases because of pride in the practice and job satisfaction, which in turn, reduces the costs of hiring and training.
► As costs go down and revenues go up, profitability increases.

Advocates, apathetics and assassins

J.D. Powers, the firm long synonymous with measuring customer satisfaction, divides the world of customers/patients into three clear categories: advocates, apathetics and assassins. They're described as follows:


► In order to create an advocate, a practice must go beyond the expected level of service and quality to create a truly memorable experience for its patients.
► Advocates are fiercely loyal, refusing to switch even in the face of aggressive promotions from competitors.
► Advocates will suffer inconveniences to purchase your services over the competition's, and may be willing to pay a premium for the privilege.
► Advocates proselytize. They tell anyone who will listen – and even some who won't – about their experiences and become your best salespeople.

Apathetics (or, the merely satisfied):

► Patients are apathetic when you just meet their basic expectations. This is why satisfaction is sometimes defined as an absence of problems. As Thomas O. Jones and W. Earl Sasser point out in a Harvard Business Review article, "Why Satisfied Customers Defect," many people use the word satisfaction not so much to express the presence of a positive feeling but rather to communicate the absence of a negative feeling. They have no compelling reason to defect but no compelling reason either to remain with you. The people who fall into this category, the authors say, are "up for grabs."
► As such, apathetics are susceptible to a competitor's advances and often need only minor inducements to switch.
► Though they tend to remain loyal, merely satisfied apathetics will not endure any inconvenience or make a special effort to use your services, let alone be willing to pay a premium for your services.
► Apathetics keep their mouths shut and tend not to speak about their experiences, good or bad.


► An assassin is created, says J. D. Powers and Associates, when you fail to meet a patient's basic expectations – or fail to rectify a problem once it has occurred.
► Assassins actively seek out your competition, defecting even if they have to pay more or suffer inconveniences to switch to a competitor.
► Research by the firm suggests that assassins are 50% more likely to tell someone about a bad experience than an advocate is to tell someone about a great experience.

Action steps For O.D.s

In the quest for turning the merely satisfied into advocates, consider the following timetested steps:

► Patient satisfaction must become an integral part of your practice culture. If you haven't given this topic a lot of thought in the past, start by asking yourself what kind of experience do you want patients to have when visiting your practice? Your answers to this question will provide you with a foundation for moving forward.
► Get the right staff on board — that is, those who will work with you to make patient satisfaction a top priority.
► Staff members must understand that the push for patient satisfaction is not just a passing phase, it's here to stay.
► Financial as well as strategic decisions must be made based on generating long-term patient loyalty, even at the expense of shortterm profits. It's important for example, to invest in state-of-the-art information technology such as EMR, and diagnostic equipment such as a digital fundus camera, corneal topographer, automated refraction system, digital anterior segment camera and ocular coherence tomography (OCT). "I have found that the more I invest in my practice with new equipment," says Darin R. Cummings, O.D., Ephraim, Utah, "the more patients invest in me as their primary eye care physician."
► Be easy to do business with. For example, a section on your website for new patients will enhance patient processing and create a great first impression. Include new patient and health history forms, directions to the office, what patients should bring or expect for their first appointment.
► The patient satisfaction commitment flows like a waterfall from the top. It starts with a doctor who:

Reality check: "If we've learned anything over the years," say J.D. Power IV and Chris Denove, co-authors of the book, Satisfaction, How Every Great Company Listens to the Voice of the Customer (Portfolio, 2007), "it is that before a company can become effectively focused on customer satisfaction, the message must be communicated in both word and deed from the senior leadership. Just talking a good game will not get it done. What separates the leaders of the companies that top our studies is that they don't just talk the talk, they walk the walk. They let everybody at the company know, from the board of directors on down to the lowest-paid entrylevel employee, that customer satisfaction is not just a buzzword, it is a commitment that the company takes very seriously."

Action steps for all staff

► Make an extra effort to be on time for appointments, deliver eyewear when promised, return phone calls when you say you will and provide the quality of care and patient-friendly service stated in your practice mission statement. Make it an unforgivable sin in your practice to make promises that you don't keep.
► The obvious secret of exceeding patients' expectations: Under-promise. Over-deliver.
► If a patient is unhappy with something they purchased, make them happy.

Our premise is simple:" says Elizabeth Spaulding, vice president of customer satisfaction, L. L. Bean Inc., "If a product doesn't meet a customer's expectations, whatever they may be, we will replace it, repair it, or refund the customer's money. The point is, the customer determines the expectation. Not us."

► Thank patients for their loyalty. "One of the biggest mistakes we've made in the past," says Dr. Tim Banker, Greens-boro, NC, "is to take loyal patients for granted – while spinning our wheels trying to get new patients. We now let loyal patients know how much we appreciate them."

Hard-learned lessons

► The practitioner who is able to fully understand the expectations of the patient at each encounter," say Stuart Rothman, O.D., Harry Kaplan, O.D., and Craig Hisaka, O.D., M.P.H., "will be the one who establishes a long-term relationship with the patient."
► Richard Boone, a McLean, VA attorney who defends doctors in malpractice cases, tells me that the common denominator in every lawsuit with which he's been involved, has been "failed expectations."
► "Core service doesn't generate loyalty," says Stephanie A. Busty, a training specialist at New York City's Beth Israel Hospital. "It's getting the service up to extraordinary levels. We want to exceed expectations. We want to knock their socks off."
► Frederick F. Reichheld, author of Loyalty Rules! (Harvard Business School Press) says that employee retention is the key to customer retention, and customer retention can quickly offset higher salaries and other incentives designed to keep employees from leaving. "The longer employees stay with an organization, Reichheld adds, "the more familiar they become with the operation, the more they learn, and the more valuable they can be. Those employees who deal directly with the public day after day have a powerful effect on customer loyalty. Long-term employees can serve customers better than newcomers can."

Retention vs. Loyalty

Finally, patient retention is not the same thing as patient loyalty. If you're the only optometrist in town, you'll retain your patients. Suppose however, other practices open up in your area, will your patients remain loyal?

Loyalty implies a choice. It's a very important distinction. OM

Dr. Levoy's newest book, "222 Secrets of Hiring, Managing and Retaining Great Employees in Healthcare Practices was published by Jones & Bartlett Publishers. E-mail Dr. Levoy at

Optometric Management, Issue: December 2009