Administration and Leadership, Patient Care, Training

The Customer’s Always Right: Steps you can take to ensure customer satisfaction

Issue 3 and Volume 35.

Does service excellence in EMS translate to better patient outcomes, more repeat business and stronger collections? The evidence of this in other areas of health care is well documented, so it’s logical to assume those results could be possible in EMS.

The age-old argument, “Those who summon our service are patients and not customers,” completely misses the point. It really doesn’t matter what we call them; individuals who seek medical assistance from EMS deserve to receive excellent service from those who provide care.

The Customer’s Voice

Airlines, hotels, restaurants and other service industries have realized that customer service makes a difference. Their patrons expect to be treated kindly, have their needs met (if not anticipated) and receive a consistent product (e.g., McDonald’s french fries). Our patients are no different.

But unlike going to McDonald’s for a quick meal, calling an ambulance is a big deal. Patients will talk about their emergency experience, and we have the ability to drive the content of that conversation. Handle it right, and your agency can benefit from repeat business, public support and proud employees. Handle it wrong, and agencies can find themselves in jeopardy.

There’s been very little formal research conducted on EMS customer satisfaction. However, in 2008, Professional Research Consultants published the “National EMS Patient Perception Benchmark Study.”

They surveyed 1,000 EMS patients from 20 different agencies in an attempt to benchmark customer perceptions about their EMS experience. Of those surveyed, 86.6% rated the overall quality of care to be “excellent” or “very good.”

The timeliness of the EMS response received a combined 79.2% “excellent” or “very good” score. EMS scores were rated higher than inpatient and emergency department (ED) scores. Individuals rating EMS were twice as likely to report an “excellent” rating as those judging the ED (58.3% versus 29.2%).

In the hospital setting, patient satisfaction is considered a required quality measure. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) hospital survey, initially a voluntary program, became mandatory for hospitals in July 2007. Hospitals participating in the Medicare inpatient prospective payment system must now collect and submit patient satisfaction data in order to receive their full payment for inpatient stays and may have 2Ï5% of inpatient payments withheld if they do not report.

As health-care reform is implemented, it’s logical to believe EMS will also be required to collect and submit patient satisfaction data as part of a comprehensive pay-for-performance program in the future.

Enhancing Satisfaction

Agencies and businesses alike have multiple opportunities to enhance patient satisfaction. Press Ganey and Associates, one of the nation’s experts in patient satisfaction, calls these opportunities “moments of truth.”

Press Ganey frequently uses the fast food experience as an example. From the time you enter the parking lot, stand in line, read the menu, place your order and sneak a french fry (or two) out of the bag, the fast-food facility has the opportunity to make or break the experience.

A discourteous employee, a dirty storage area or driveway covered in litter can all tarnish the customer_s perception of the facility and affect future business.

The EMS experience can be scrutinized in the same manner. The 9-1-1 call, arrival of first responders, paramedic arrival, assessment, protection of privacy while performing a 12-lead ECG, movement to the unit, transport, transition of care at the ED and arrival of the bill all present opportunities for you to enhance patient satisfaction.

Patient satisfaction can determine collections, profits (limiting losses), return business, compliance to care and the customer’s impression of competence. Some providers believe that happy patients don’t litigate.

In fact, EMS patients who rate the overall quality of care as “excellent” are almost five times more likely to recommend the agency than those who rate their care “very good.” This research shows that patients’ ratings of overall quality is closely tied to loyalty. One could argue that repeat business and referrals could lead to higher revenue for EMS firms with outstanding customer service.

Listening to the voice of the customer allows service providers in every industry to tailor their service to promote a satisfying customer experience. Health care is no exception. Health-care providers should strive to consistently provide exceptional service regardless of which EMS provider is delivering the care. We desire consistency in the application of protocols; we should seek it in all aspects of the care we provide as well.

Assessing Patient Satisfaction

We have a biased view of what we think our patients want from EMS. We tend to believe our patients and their families value our life-saving skills above all else. Therefore, we sometimes tolerate poor bedside manners in our peers because we know they have excellent advanced skills.

Patients usually aren’t qualified to evaluate the proficiency of our life-saving skills, but they are more than qualified to fully assess our interpersonal skills. And frankly, life-saving skills may be used on less than 1% of patients; our interpersonal skills are assessed 100% of the time.

A colleague once summarized the EMS patient’s expectations to four simplepoints: 1) Get there quickly; 2) Be nice to me; 3) Tell me what you’re doing, and 4) Take away my pain. In 2009, Press Ganey and Associates’ hospital-based research correlated patient satisfaction score to a patient’s likelihood of recommending a health-care facility. The 10 items with the highest correlation were:

  1. Staff worked together to care for them;
  2. How well their pain was controlled;
  3. Staff included them in decisions about their treatment;
  4. Skill of the nurses;
  5. Nurses’ attitude toward their requests;
  6. Staff addressed emotional needs;
  7. Nurses kept them informed;
  8. Response to their concerns and complaints;
  9. Staff attitude toward visitors; and
  10. Friendliness and courtesy of the nurses.

This research demonstrates that patients want to be kept informed and treated well.

Finding the Right Tool

An ideal satisfaction monitoring tool is designed to measure feedback on important elements of key moments of truth. There are three popular methods of assessment.

Third-party approach:Most health-care experts advocate this approach that utilizes such groups as EMS survey and research consultants. Using a third party provides an economy of scale, a level of objectivity and anonymity that in-house programs cannot achieve. In addition, they allow you to benchmark your agency against a large database of other providers.

In-house approach: Many agencies use an in-house approach. Direct mail and personal calls are most common and can be a cost-effective way to assess the customer’s perspective. In-house approaches are easy to administer, but they may not be statistically validated and could contain unintentional bias. Under this approach, trending of patient satisfaction data can be accomplished, but comparative data isn’t available unless agencies partner for this purpose.

Point-of-service approach: This assessment approach is less common, but it’s the one we use at Montgomery Country Hospital District. Our agency provides an on-the-spot survey to patients upon delivery at the hospital. Typically a business reply card, this survey tool asks four key questions about our service and offers the opportunity to comment. Questions include:

  1. Did we arrive in a timely manner?
  2. Did we explain the treatment you received?
  3. Were you treated in a respectful manner?
  4. Were we able to make you comfortable?

With this assessment method, EMS crews explain to their patients that a larger survey will come in the mail, but that they also want to offer them the opportunity to provide immediate feedback.

Scripting for Success

Regardless of the survey tool you use, the data should indicate your customer’s perspective. There are two simple ways to enhance patient satisfaction in EMS: scripting for success and service recovery.

Noted health-care consultant and author, Quint Studer, advocates the use of scripting (i.e., key messages) as opportunities to keep patients informed and reset their expectations to the reality of the experience. The concept is simple: Guide the patient’s expectations toward reality, meet their expectations, and they will have high satisfaction with the experience.

Scripting personalized communication with a predetermined meaning ensures consistent messaging across your organization and guides actions in difficult situations. Scripts define the words and behaviors you expect in a situation, increasing the chance that you send the message you want. Every employee who has any interaction with customers should have some sort of script defining acceptable words and behaviors.

For example, scripting can prepare a patient for a procedure. As intermediate and paramedic students, we learned to tell the patient, “This might hurt a little,” before sticking them with a needle.

Scripting can also defuse a potentially dissatisfying experience. For example, we know that some patients routinely complain about the roughness of the ride and skill of the driver.

So, we recommend that our crews tell the patient, “(Name of driver) is a safe driver, and I trust him with my life. The ride to the hospital will be a little rough; you know the roads around here. He’ll do everything he can to offer you a smooth ride. Tell me if there’s anything I can do to make you more comfortable.”

We can’t fix the roads, nor can we change the fact that we’re riding in a vehicle built on a truck frame, but we can set their expectation and operate in a safe manner.

By listening to the voice of the customer, our service also realized we were setting ourselves up for failure in pain management. Despite a very assertive approach to pain management, our satisfaction scores were very poor.

After interviewing patients and observing our medics, we realized that we were scripting against success. We told patients we were going to take their pain away. When they still experienced some pain, they were dissatisfied.

So, our staff developed a new script: “Mr. Jones, I’m going to give you some medicine to reduce your pain. You will likely still feel some pain, so please tell me if there_s anything I can do to make you more comfortable.”

Scripting also provides you with an acceptable way of delivering messages or asking difficult questions. For example, you respond to a “sick person” call at 3 a.m. The patient tells you they’ve been feeling ill for two days. You could ask, “Why did you call us at 3 a.m. for this?”

However, doing so may cause the patient to question why they called or perceive that you’re uncaring. So, we encourage our staff to ask a scripted question, “Was there some change in your condition that prompted you to call for us right now?”

Finally, scripting can reveal things that the patient might not sense on their own. Patients have a strong need for privacy. We can’t change the fact that we’re transporting them on a cot to an ambulance parked in their front yard after partially disrobing them.

However, we can put them at ease by saying, “Mrs. Smith, your privacy is very important to us. We’re going to move you to the ambulance as quickly and safely as possible. We’ll keep you covered, and we’ll close the doors as soon as we get in. Do you have any questions?”

Encourage your staff to develop appropriate scripts that address key moments of truth in the prehospital experience. Remember that scripting starts with the voice of the customer. Patient feedback, including complaints, can provide the launch platform.

Service Recovery

Mistakes happen. We know that, and so do our customers. But mistakes don’t have to ruin the patient experience. When mistakes occur, act quickly and responsibly to make it right, and you can recover the service experience.

Several years ago, while responding to an ill, older patient, one of our personnel accidently bumped the patient’s even older mother. The mother lost her balance and fell, fracturing her hip. The crew member couldn’t have been more remorseful. They called a second ambulance and did all they could to make both patients comfortable.

Our agency dispatched a “service recovery team” to the hospital. We met with the family to express our deep regret. We said, “I’m sorry.” In addition to writing off their bills, we sent them a special cheese platter. No adverse action came from what could have been a public relations and litigation nightmare because we took responsibility for our actions, took care of the family’s needs, and the family was understanding.

The on-the-spot survey mentioned earlier is an excellent service recovery tool. When we’ve failed to meet the patient’s expectation, we encourage crews to offer a card and say, “We realize we did not meet your expectation. We’re sorry for that. Please use this card to tell us how we can do better if you ever need our service again.”

We’ve found such action to be incredibly defusing. The comments were, in this circumstance, generally constructive and appreciative. Customers who have a service failure that’s resolved quickly and properly aremore loyal to a company than customers who’ve never had a service failure—significantly more loyal.

Employees should be responsible for recognizing the need and initiating service recovery. In the hospital setting, it’s common for employees to be allowed (within predetermined limits) to incur expenses for service recovery.

Having the housekeeping staff deliver flowers or offering free parking is a small price to pay for customer satisfaction. It sends a message that the entire organization is united in a mission to provide service excellence. Hospital administrators tell me their overall annual cost for service recovery is nominal.

Although this is slightly more difficult in a decentralized EMS environment, the concept should be the same. Recently, we had a crew leave the hospital after a difficult call. Things didn’t go as well as they had hoped, and they realized the patient wasn’t happy.

They understood service recovery and asked if they could take a baseball cap and a blanket embroidered with our company logo on it to the family. They expressed regret that they didn’t meet the family’s expectation and presented them with the items.

The family was overwhelmed and told everyone they had contact with at the hospital how much our staff cared. The items cost $20. The family paid the entire bill with the first invoice.


EMS is a relative newcomer to the customer satisfaction experience. Hospitals have been assessing the patient experience for years and have sophisticated approaches to developing employee commitment, scripting and service recovery. Agencies wishing to create innovative approaches should learn how their primary hospitals have achieved success in this area.

In the hospital and hospitality industries, customer satisfaction and repeat business are important concepts. Although equally important for non-emergency transport providers, 9-1-1 system providers may not recognize the importance of brand loyalty. In the end, our patients will have an impression about our servi ce that they will communicate to family, friends, and perhaps elected officials.

Although the body of knowledge on EMS satisfaction is limited, there are lessons all around us. It’s up to us to look outside our industry for best practices and learn to adapt them to our environment.

If there_s still any question why customer satisfaction is so important, it_s clear from our hospital partners that our future reimbursement may depend on how well we meet the expectations of those we serve. Regardless, service excellence should be part of our everyday mission. JEMS


  1. U.S. Department of Health & Human

    Professional Research Consultants.
  2. Smith A.K., Bolton R.N.: An experimental investigation of customer reactions to service failure and recovery encounters. Journal of Service Research. 1998;1:65–81.
  3. Press Ganey Associates, Inc. Hospital Pulse Report 2009. Press Ganey Associates, Inc. Southbend, Indiana. 2009.


Five Steps of Service Recovery

  1. Expressing Regret: “I am sorry that we did not meet your expectations”
  2. Accepting Responsibility: “That is not the way we would like it to happen.”
  3. Making Restitution: “What can I do to make it right?”
  4. Genuinely Repenting: “We will work with the staff to ensure they are better prepared to meet your expectations”
  5. Requesting Forgiveness: “I hope that you will have confidence in us in the future.”„„


Recommended Reading

  • If Disney Ran Your Hospital: 9-1/2 Things You Would Do Differently by Fred Lee
  • From Worst to Firstby Gordon Bethune
  • Nuts! Southwest Airlines’ Crazy Recipe for Business and Personal Successby Kevin Freiberg
  • The Baptist Health Care Journey to Excellenceby Al Stubblefield
  • Hardwiring Excellenceby Quint Studer
  • The Three Signs of a Miserable Jobby Patrick M. Lencioni
  • Customer Service in Health Care by Kristin Baird
  • PRC National EMS Patient Perception Benchmark Study