Customers’ assessments of quality and value, decisions about what and where to buy, and recommendations to others are all influenced by emotions. But too often companies don’t adequately anticipate those emotions and therefore can’t mitigate negative ones in the design of their offerings. This is especially true for high-emotion services—those that trigger strong feelings before the service even begins. Services relating to major life events such as birth, marriage, illness, and death fall into this category, as do airline travel, car and computer repair, and home buying, selling, and renovation.
High-emotion services may elicit intense feelings for the following reasons:
Lack of familiarity with the service being delivered. When family members must quickly arrange a loved one’s funeral, their grief is often compounded by uncertainty surrounding expenses and options.
Lack of control over the performance of the service. Complaints about auto repair shops regularly top lists published by the Consumer Federation of America.
Major consequences if things go wrong. Legal services for a divorce can have a huge effect on a client’s finances, child custody, and self-esteem.
Complexity that makes the service a black box and gives its provider the upper hand. When a computer technician tells a customer that “the laptop’s motherboard is fried,” the customer usually has no way to judge either the diagnosis or the suggested repair.
Long duration across a series of events. A wedding commonly involves extended planning, a rehearsal dinner, the main ceremony, and some combination of reception, meal, and party—plenty of opportunities for conflict and pitfalls.
Satisfying anxious or overwrought customers who are contending with these issues is a challenge for service providers. Drawing from our collective experience studying, designing, and providing services, we have identified four guidelines that can help positively influence expectations and perceptions of quality and value, enhancing customers’ satisfaction and loyalty. Managers should identify emotional triggers, respond early to intense emotions, enhance customers’ control, and hire and rigorously train people who can communicate respectfully.
A Traumatic Journey
We chose cancer care to illustrate the application of these guidelines, for an obvious reason: Few services involve more-intense emotions. A cancer diagnosis is life changing. It immediately raises the specter of death, typically involves long treatment cycles and multiple clinicians, and often heralds acute short- and long-term physical and emotional side effects of the treatments themselves. The foundation of excellent cancer care is and always will be the quality of the diagnosis, the treatment plan, and the clinical services. But compassionate, sensitive delivery matters a great deal in shaping the reputation of a care organization and distinguishing it from competitors. In addition, a portion of Medicare reimbursements to hospitals is now tied to customer satisfaction ratings.
One of us (Len Berry) is conducting an ongoing study of how to improve the service journey that adult cancer patients and their families take from diagnosis through treatment, recovery, and in some cases end-of-life care. So far, the research has involved interviews with more than 350 cancer patients, family members, oncologists, surgeons, oncology nurses, nonclinical staffers, and leaders of health care organizations, primarily at 10 highly reputed cancer centers in nine U.S. states. For example, Bellin Health Systems, based in Green Bay, Wisconsin, was rated the safest hospital in America by Consumer Reports in 2013; Mayo Clinic attracts patients from all over the world to its three main sites in Minnesota, Arizona, and Florida, owing to its reputation for clinical quality; and Intermountain Healthcare, based in Salt Lake City, is a trailblazer in using analytics to minimize unwanted clinical variation across physicians and delivery sites.
The institutions studied are known for their service quality as well. Their delivery of high-emotion services was a primary factor in their selection for the study.
Consider Bellin Health. For most of its 100-plus years, Bellin’s cancer services were limited primarily to surgery at its main hospital; patients received outpatient care from other providers. But by the early 2000s competition was intensifying, oncology admissions to the hospital were declining, the surgeons were frustrated by the lack of timely, coordinated outpatient care, and patients were asking why they couldn’t receive all their treatment at Bellin. During an effort to create a comprehensive cancer center, the board of directors instructed the steering team (led by one of us, Jody Wilmet) not to merely duplicate what the competition was doing but to differentiate patient care. The team decided to meet that challenge by designing high-quality services that would also address the emotional needs of patients and their families.
The cancer center, which opened in 2008, surpassed its five-year growth and revenue targets in just two years, and nearly 100% of patients (who are regularly surveyed) say they are “highly likely” to recommend its medical and radiation oncology services. Bellin achieved these results in large part by following the four guidelines for succeeding in highly emotional contexts. Let’s look at each one in turn.
1. Identify Emotional Triggers
The initial emotional trigger is a need for the service, and a company’s underperformance can heighten negative emotions such as anger and fear. But emotions also present opportunities to exceed customers’ expectations. Identifying the aspects of a service that are most likely to intensify negative emotions is a key step in developing a strategy to minimize those emotions. The process can range from the simple (surveys, focus groups, interviews) to the sophisticated (controlled experiments and experience mapping). The purpose is to encourage customers to probe and express their deep feelings about the service and to voice needs, concerns, or hopes that might not otherwise surface.
Open-ended prompts about common frustrations can be particularly revealing: “Describe the worst experience that you or a family member ever had when using this type of service.” “If you were the CEO of this organization for a day and could make just one improvement for customers, what would it be?”
Bellin used patient focus groups to inform the design of its cancer center. For instance, breast cancer survivors who had been diagnosed or operated on at Bellin were asked how they would design the center if money were no object. The vast majority said it should not be inside the flagship hospital, which they perceived as a complex, scary, and inconvenient place. So Bellin designed a freestanding facility and located it off a major highway several miles from the hospital. The center houses all oncology and administrative staff members and provides comprehensive and coordinated care. (The health system branded its service as the Bellin Cancer Team.) The facility not only makes it easier to deliver efficient service but also offers a calming experience for patients: easy parking; serene design using soft colors, stone, wood, and natural light; and a garden visible from the infusion room. Without patient input, Bellin would have followed a consultant’s recommendation to simply add a cancer wing to its hospital.
Bellin also uses experience mapping in an effort to better identify and respond to patients’ emotional triggers.
Capturing customers’ full emotional processes is challenging. Bellin Health uses an innovative technique from The Karma Group called RiverMapping to better understand its patients’ cancer journeys. Patients receive detailed instructions on how to draw a map of the twists, turns, obstacles, turbulence, and smooth waters they experience.
The gynecologic oncology patient who created the RiverMap shown here drew rapids to express the stress of waiting for biopsy results and coping with skin damage from radiation treatment. She drew more-violent rapids to represent a meeting with new doctors to plan skin treatment after evidence that her cancer was gone—a surprise that prompted Bellin’s staff to probe why she felt this way.
Trained facilitators discuss the maps with patients and have learned, for example, that patients see how a doctor or a nurse treats their families as an indication of how much the provider cares about them. Patients often include aspects of their personal lives, such as trouble with work or relationships, and nonclinical care, such as patient registration, in their maps. This can be illuminating for clinicians.
2. Respond Early to Intense Emotions
In times of duress, the impressions left by service providers are long-lasting and can heighten the impact of a service experience, for better or worse. A failure to recognize and quickly respond to their emotional states leaves customers feeling scared, frustrated, powerless, and ignored. Here are some tactics for avoiding those feelings:
Prepare customers for what’s next.
Many high-emotion services are long-term and include numerous discrete experiences of varying intensity. Not knowing what lies ahead is a major source of anxiety for customers, who often imagine worst-case scenarios. “With cancer, there is a sense of urgency,” one patient commented. “Everyone is upset when waiting for the diagnosis. As a patient, you want to know ‘What’s the plan?’ Something is growing inside you. Let’s get on with it.”
Consequently, attending to customers’ needs in a timely, thorough manner is crucial to moderating their emotional intensity. In many areas of the United States, newly diagnosed cancer patients have to wait several weeks or more to see various specialists and begin treatment. In stark contrast, Intermountain Healthcare offers a comprehensive set of medical appointments over the course of one day, typically within a week of the diagnosis. Patients and their families sit in one room during their “multidisciplinary clinic” day, and the members of the care team (for example, a surgeon, a medical oncologist, a radiation oncologist, a dietician, a social worker, and a nurse “patient navigator”) individually come to them. At the end of the day, patients receive a written care plan that includes scheduled appointments.
Timothy Crowley and Alex Metzger, oncologists at Marin Cancer Care, a private practice outside San Francisco, stress the importance of the personal touch in the initial meeting with a patient after he or she has received the diagnosis. “Anxiety is high, and I try to get patients to take a deep breath,” Crowley says. “I explain what’s going on, take them through what treatments may be involved, and reassure them to the degree possible. You never want patients to feel rushed.” Metzger adds, “It is really important in the first visit to establish a relationship with the patient and start a plan.”
The beginning of every stage of a long-term service, not just the first, can heighten emotions—so each stage is a prime opportunity for an organization to build customers’ confidence. It is important to explain what to expect from each stage. Provide the information in a form customers can digest at their own pace, and repeat the most important aspects. Instill trust through transparent, reassuring communication.
Prior to a patient’s first chemotherapy or radiation session, the staff members of well-run cancer centers review the process step-by-step and answer questions. Ideally, the staffer who educates the patient about upcoming treatments will also administer the first one to take advantage of the established relationship. Asked about his first chemotherapy treatment, one patient recalled: “At that time, I knew what I was dealing with. I felt armed with what the nurse had taught me. I remember feeling positive and strong. Being prepared made it much better.”
The North Shore–LIJ Cancer Institute, one of the largest providers of cancer care in the New York metropolitan area, gives radiation patients and family members tours of the treatment rooms in advance. “Patients will fear the machine less if you show it to them,” explains Magdalena Ryniak, the director of patient care services for radiation medicine.
Another critical phase that requires preparation is the end of treatment, which may generate a mixture of relief and deep anxiety. Even patients whose cancer is in remission may be emotionally challenged by the fear of recurrence, the impending loss of their medical support network, and, possibly, the stigma (real or imagined) of having cancer. Many progressive cancer centers offer formal survivorship programs, which in 2015 became an accreditation standard of the American College of Surgeons Commission on Cancer.
Bellin was an early adopter. At the end of treatment, its patients meet with a nurse practitioner who specializes in cancer aftercare. “The end of treatment is a teachable moment,” says Patti Marquardt, a nurse who administers the program. “Patients say, ‘I’ve survived this. I got through it. How do I stay healthy?’” Patients receive take-home information summarizing their treatments, symptoms of recurrence, when to seek medical help, ways to manage physical changes, and fitness planning. Their primary-care physicians also receive the summaries.
Monitor for emotional spikes.
Predicting exactly when a customer’s emotions will intensify is often impossible. Spotting spikes requires monitoring. They can occur for any number of reasons: surges in pain, severe side effects from medication, changes in physical appearance due to the disease or to treatment, family-related stress (from having to tell children that their father has cancer, for example), financial pressure (even for patients with health insurance, who may be unable to work or whose insurance may not cover a certain prescribed drug), and “bad news” days, such as when the patient learns that the cancer has spread.
Progressive cancer centers periodically administer comprehensive assessments to keep tabs on their patients’ physical and emotional states. Mayo Clinic’s Phoenix campus was among the first to use iPads for this. Palliative care patients (who receive an extra layer of care for symptom management and psychosocial concerns) complete a questionnaire on an iPad, usually while in the waiting room prior to seeing a doctor. The physician can access their responses during the appointment. The assessments cover the patients’ physical and emotional health, personal relationships, financial concerns, and difficulties with medication or with work. Questions about satisfaction with physician care are also included; they can reveal problems underlying the escalation of a patient’s emotions.
Communicate with care.
The body language, choice of words, tone of voice, and appearance of staff members can have a big impact on anxious customers who are looking for evidence of competence and compassion and want to be reassured that they have chosen a good provider. A valuable exercise is to convene top providers and ask them to identify phrases that needlessly undermine customers’ self-esteem, confidence, or hope. These “never phrases” can be incorporated into training sessions for the purpose of eliminating them.
Patients with advanced disease should never be told “There is nothing left to do,” says Peter Eisenberg, the founder of Marin Cancer Care. He might instead tell them, “Let’s focus on how well you can live, not how long you will live.” All service sectors have never phrases. The key is to find and banish them.
3. Enhance Customers’ Control
One aim of redesigning service experiences is to give customers a greater sense of control and peace of mind. Time can seem to stand still for anxious people who need a service but have no access to it. In her powerful essay “Don’t Get Cancer Over the Holidays,” published in 2009 in the Yale Journal for Humanities in Medicine, Diana Burgess describes her emotional trauma upon being informed a few days before Christmas that she had cancer by a doctor she had never met who left the next day for a multiweek vacation without arranging any backup services to assist her. Burgess relates her panic and desperation—and deep resentment—when she was snubbed by the on-call physician as she sought information about her test results: “I get off the phone, shaking. How dare she talk to me like I am a stalker, like I got her phone number out of the phone book and tracked her down? ‘You were the doctor on call,’ I think. ‘It’s your job. It was your practice that blew me off today when I called during business hours, your practice that never answered my calls.’ This experience of being abandoned by the medical system, at the time in my life when I most needed a guide, the frustration of not knowing how to get the answers I so desperately wanted, had turned me into a crazy person.”