From Customer Satisfaction to Customer Bliss Optimizing Your Customer s Experience

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Topics to be Covered. Defining consumer satisfactionImportance of consumer satisfactionWhat's important to the end userActions to improve customer satisfaction. Defining Customer Satisfaction What is customer satisfaction

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From Customer Satisfaction to Customer Bliss Optimizing Your Customer s Experience

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1. From Customer Satisfaction to Customer Bliss Optimizing Your Customer’s Experience Sergei Kochkin, Ph.D. Better Hearing Institute

2. Topics to be Covered Defining consumer satisfaction Importance of consumer satisfaction What's important to the end user Actions to improve customer satisfaction

3. Defining Customer Satisfaction What is customer satisfaction & what is benefit?

4. 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.

5. 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

6. Some Synonyms for Satisfaction

7. 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"

8. 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

9. 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.

10. Importance of Customer Satisfaction Business is made up of the largest group of volunteers in the world......customers!

11. Consumer Satisfaction is Important to Health of Hearing Aid Industry

12. Consumer Satisfaction is Important to Health of Hearing Aid Industry

13. Consumer Satisfaction is Important to Health of Hearing Aid Industry

14. Reasons for Non-purchase of Hearing Instruments

15. 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.

16. 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

17. Impact of Customer Dissatisfaction Higher employee turnover & absenteeism Lower staff morale Lower compliance with instructions More malpractice suits Lower profitability

18. What Customers Want

19. Relative Importance of Factors on Overall Consumer Satisfaction

20. Impact of Improving Multiple Environmental Listening Utility (MELU) on Overall Satisfaction (All hearing aid owners n=2,572)

21. Relative Importance of Factors on Overall Consumer Satisfaction

22. 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.

23. 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

24. Factors Most Related to Overall Customer Satisfaction Benefit at a good value Better sound quality Better Reliability Multiple Environmental Listening Utility (MELU)

25. Hearing Aid Improvements Sought by Current Hearing Aid Owners (n=2,428) (Highly desirable scores =4-5 on 5 point scale)

26. Hearing Aid Improvements Sought by Current Hearing Aid Owners (n=2,428) (Desirable scores =4-5 on 5 point scale)

27. Improvements Sought in Hearing Instruments Speech intelligibility in noise Better sound quality Less whistling & buzzing (feedback) Lower price More soft sounds audible

28. The Consumer’s Perspective: “Why My Hearing Aids Are in the Drawer”

29. 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%

30. 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.

31. Hearing Aids in the Drawer are Related to Age of the Instrument But a third are New Hearing Instruments

32. What are the top 3 reasons why hearing aids are in the drawer?

33. Reasons for Non-Use Poor benefit (30%) - 268,507

34. 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.”

35. 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.”

36. 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.”

37. 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.”

38. 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.”

39. Reasons for Non-Use #1. Poor benefit (30%) - 268,507

40. 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.”

41. 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.”

42. 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.”

43. 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.”

44. Reasons for Non-Use #1. Poor benefit (30%) - 268,507 #2. Background noise (25%) - 229,383

45. 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.”

46. 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.”

47. Reasons for Non-Use #1. Poor benefit (30%) - 268,507 #2. Background noise (25%) - 229,383 #3. Fit & Comfort (19%) - 169,431

48. 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

49. 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 Negative Side-effects

50. 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

51. 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.”

52. 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.

53. 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.”

54. 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.”

55. 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

56. 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

57. 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

58. Key Findings 907k inactive hearing aid owners in the United States (1997). Key reasons: Poor benefit Background noise Fit and comfort

59. 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.

60. 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

61. 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.

62. What Can the Industry Do to Improve Customer Satisfaction?

63. Customer Satisfaction is a Complex Issue

66. What Needs are we Trying to Meet in the Hearing Aid Market?

67. 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

68. 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.

69. 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

70. Use the Findings From the NCOA Study Become very familiar with the executive summary of the study Kochkin & Rogin. Quantifying the Obvious : The impact of hearing aids on quality of life (Hearing Review, Jan. 2000) Counsel your potential clients on the benefits of hearing aids. 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

71. 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

72. 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

73. 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.

75. 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

76. 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

77. 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)

78. Typical Usage Satisfaction by Generic Feature

79. Multi-environmental Value Satisfaction by Generic Feature

80. Total Subjective Benefit by Generic Feature

81. Satisfaction by Technology on Overall Satisfaction

82. Satisfaction by Technology on Sound Quality

83. Satisfaction in Difficult Listening Situations by Technology

84. Satisfaction in Difficult Listening Situations by Technology

85. 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

86. 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

87. Omni versus Directional Hearing Instruments MarkeTrak VI (October 2002 HR)

88. Customer Satisfaction Improvements of at Least 15% Due to Dual-microphone (Directional) Technology (H.I. < 6 years of age)

89. Summary of Impact of Directional Microphones on Customer Satisfaction

90. 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

91. Significant Differences Overall, Consumer Behavior & Dispenser

92. Significant Differences Product Features

93. Consumer Need for a Volume Control

94. Customer Satisfaction is related to Need for a VC

95. Significant Differences Performance Factors

96. Significant Differences Performance Factors (Cont.)

97. Significant Differences Listening Situations

98. Significant Differences Listening Situations (Cont.)

99. Summary of Key Findings

100. 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).

101. 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.

102. 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).

103. 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.)

104. 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.

105. Recent Research with MicroWaxbuster Demonstrates it Will Dramatically Reduce Hearing Aid Service Rates

106. 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.

107. 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.

108. Receiver replacement rates per 100 CIC hearing aids (n=21,345)

109. Receiver replacement rates per 100 ITC hearing aids (n=47,316)

110. Receiver replacement rates per 100 ITE hearing aids (n=21,647)

111. 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.

112. 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

113. Soft Shell Technology Improved fit & comfort Improved fit with torturous ear canals Other potential benefits: > gain before feedback < displacement of hearing aid

114. 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)

116. 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

117. 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?

118. 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

119. 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)

120. MarkeTrak Norms: Select Customer Satisfaction Factors

121. MarkeTrak Norms: Customer Satisfaction in Select Listening Situations

122. Percent of Consumers Receiving Follow-up Customer Satisfaction Survey (H.I. < 6 years compared to H.I. <1 year in age).

123. Overall Satisfaction Improves with Post-fitting Survey Follow-up (H.I. < 6 years compared to HI < 2 years).

124. 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

125. 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?

127. From: Evidence for the Binaural Advantage Using Customer Satisfaction & Benefit Data. (Kochkin, Kuk 4/1997)

128. U.S. Binaural Hearing Instrument Owner Population Trend

129. 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

130. 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

131. 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.

132. Satisfaction with Directionality of Hearing Aid for 5 Samples of Bilateral Loss Subjects Fit Either Monaurally or Binaurally.

133. Monaural vs. Binaural Customer Satisfaction (Key factors impacted)

134. 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%

135. 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): (market research section).

136. 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.

137. 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.

139. 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.

140. 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.

141. 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.

143. 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

145. Amount of Counseling Time Spent with Hearing Aid Users During Last Hearing Instrument Purchase (H.I. < 6 years compared to H.I. < 1 year).

146. Customer Satisfaction Ratings are Related to Time Spent in Counseling (H.I. < 6 years compared to H.I. < 1 year).

147. 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

148. 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

151. 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.

152. Current Nonowner Attitudes Toward U.S. Hearing Health Distribution Channels

153. “People buy from people... people they like, they trust, they respect; no one buys from an enemy." Sales Manager - Dupont

154. 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

156. 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.

157. Comprehensive Fitting Protocols Models of hearing aid success needed: Matching technology with consumer hearing loss characteristics at the point of sale.

158. 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

159. 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.

160. 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”

161. 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*

162. 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.

163. 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.

164. Best Practices Discussion Items

165. 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

166. 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?

167. 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)

168. 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)

169. 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 end-user.

170. 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

171. 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

172. 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?

173. 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.

174. 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.

175. 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).

176. 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 energy expenditure (time, service, product).

177. 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

178. 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

179. 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

180. 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.

182. Value 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.

183. 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

184. What is Value? Service provided + performance of hearing instrument (benefit) Relative to how much was paid for the product & service

185. What is value?

186. Customer Satisfaction is Highly Related to $$$ Spent per 1% Improvement in Hearing Disability

187. Overall Customer Satisfaction as a Function of Price and Hearing Disability Improvement (Statistical Model)

188. Hypothetical Situations - Value

190. Satisfaction is Related to the Age of the Hearing Instrument

191. …and to Hearing Aids in the Drawer

192. 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.

194. 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.

195. A Word About Expectations Set unrealistic expectations--in essence, promises you can never hope to keep--then: your customers will hold you beneath contempt.

196. 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) – Rose Allen – 5/20/02

197. What Can You do to Move From Customer Satisfaction to Customer Bliss in Your Practice?

198. 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.

199. 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)

200. 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

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