What People Say: Fielding and Responding to Customer Complaints

One of the toughest jobs in EMS is rarely mentioned along with intubating bloody airways or extricating people from upside-down cars on cold, rainy nights. You won't find guidelines for doing it properly in any EMS text, and you won't see the topic offered at educational conferences. But it's vital just the same. People in EMS agencies are doing it everywhere, right now. And anytime they bungle the job, they can expect awful consequences.

It's the skill and art of handling their customers' complaints.

None of us are perfect, especially considering the challenges we face every day. And if we're not perfect, then neither are the organizations we work for. So, complaints are inevitable--especially considering the sky-high expectations of our customers.

The Value of Feedback

Some EMS agencies pay professional consultants big money for advice on how to improve their systems. That's good, because it demonstrates their sense of accountability to the public. If you don't believe in that kind of accountability, you should expect to wake up some day immersed in a nightmare that's all too real.

But the most knowledgeable experts about your agency's service are not outsiders. They're the people who have sampled its end results first-hand and on the worst days of their lives. Their observations can tell you more about your mission, your recruitment and selection processes, your equipment, your training programs and your organization's heart than any other expert you'll ever find.

They're the people you serve.

Think about it. They're all around you. It's in their nature to watch and assess everything you do. They share their observations willingly and without charge, whether you ask for them or not. And if you're not willing to listen, they'll eventually find someone who is.

If you're like most of us, you don't get too excited about free advice. After all, as the saying goes, it's only worth what you pay for it. But considering that it's coming from your ultimate bosses, maybe you should listen. In fact, maybe you should do more than listen. Maybe you should solicit their feedback, routinely and systematically. Then listen.

It's essential for every organization that serves people to possess something called customer sense. Essentially, customer sense is anything that would make sense to a customer. Without a thorough understanding of its customers' needs, no service organization can last very long.

You don't have to belong to a big organization to track your customers' feedback, and you don't have to be a statistician. You only have to care about it. That matters more than anything, because you can't help communicating it to a customer in the way you answer your phone, return their messages and listen to what they have to say.

Customer Satisfaction Surveys

Did you roll your eyes when you read that line? Don't worry. This doesn't need to be science, and you won't need to spend a lot of precious resources. But no matter how your system is financed, a simple written customer survey is one of the best investments you can make.

Your survey can consist of fewer than 10 questions, and you can mail it out with your billing materials. It should be simple and it should be designed with plenty of input from your crews. Specifically, it should gather two kinds of feedback:

1) What you want to know, and

2) What your customers want to tell you.

Those can be two very different things; but they're equally important if you want to understand and improve the quality of your service.

Build the first batch of questions around the mission of your organization, but keep them specific. If your mission is to provide great customer service, that's too vague. Instead, ask your people to decide how customer service should be defined. Examples might include: the use of names, the use of pillows and blankets, prompt arrival, politeness, comfort during transport and cleanliness of the ambulance.

The second batch should consist of not more than a couple of open-ended questions, each allowing space for a narrative answer. The answers to these questions will often be the most telling, as customers take their own time and choose their own words to tell you about their experience. Remember, patients don't know how to calculate dopamine drips. They do know, more than anybody else, how your service makes them feel. (That dopamine dosage is also part of customer service, though, and needs to be scrutinized separately through your medical chart review process.)

However you do it, make your survey brief, simple and easy to complete. Make sure it doesn't cost your customers anything to mail. And develop a process that alerts the right person to handle it immediately if a survey form comes back as a written complaint.

Investigating Complaints

History is supposed to be more than a reading exercise. It's full of important lessons we should only have to learn once. With that in mind, it seems incredible how many persist in repeating the history of one of our most common mistakes--immersing good people in punitive, fear-based environments. Don't do that to your organization. It can turn a fine workforce into an army of adversaries who can generate more complaints than you can imagine.

Complaints most often seem to come to field leaders, and that works fine. But beyond simply answering questions, handling complaints is a job for someone who has time to do the job right. It's also a job for someone who likes doing it. Why? Even if you rarely receive complaints, every single one of them can escalate into your agency's worst nightmare. Designate a particular person who is good at doing investigations and dealing with angry people. Make sure this person is easily accessible. That's not bureaucracy; it's rational allocation of the proper resources that can be crucial when an incident occurs.

Ideally, a complaint handler needs to be a good fact-finder and an excellent communicator (equally skilled at listening, speaking, reading and writing well). They also need to have an abiding respect for field providers, as well as for customers. Personally, I think that demands plenty of field experience.

The complaint handler should be charged with two main responsibilities, in this order:

• To protect the rights of crews as well as the rights of the public;

• To enable your organization (from top to bottom) to determine the truth about its service and learn from it.

Does that mean you have to create new positions? Not at all. Experienced paramedics are by definition experienced investigators. The same is true of people with police, journalism or PIO (public information officer) training or backgrounds. A field leader may also be the best person for the job. But not one who's too busy to do it well.

Experience has shown that if you hire good people, respect them and teach them how to take care of customers, you should receive relatively few complaints. But positive comments are also very important to handle well, and are just as powerful.

Harnessing Positive Feedback

The survey form you use to track your complaints is an important way of telling your people how much their efforts are appreciated. Post the forms weekly on bulletin boards ("Atta-Boards") that are located prominently in your main station(s). Make it a weekly priority to maintain them consistently.

Ranking the forms is a good idea. For instance, letters and cards might receive a little more space and appear in the upper left corner as a place of honor. You might also embellish some of the forms by highlighting certain words like "kind," "caring" and "gentle," which are identifiable with your mission statement. You can also use balloon messages to encourage and celebrate your crews' work.

Those things are very important to people who have knowingly chosen a profession whose greatest rewards will never be financial. It can matter a lot to them that your agency values their role in generating positive customer feedback, and that you take that feedback seriously.

In addition to feedback from external customers, maintain a system to track internal feedback. When a crew goes out of its way to clean another crew's equipment so shift members can finish their documentation and get off on time, that's a big deal every time it happens. They deserve recognition for it. The same is true for a crew that spends its down time cleaning the station or storing supplies. In fact, you could view the occurrence or absence of these kinds of things as indicators of the health of your organization.

In addition to tracking feedback, it's important to have a system for tying it into the performance review process. Try using an inexpensive page scanner (like the Minolta, Hewlett Packard or Brother multifunction inkjet printers) to scan your materials (forms, letters, notes, cards, etc.) as they come back from customers. Then insert every individual scan in a PowerPoint file for each employee.

Scan everything in black-and-white mode (not grayscale) to minimize file sizes. Save the files at a resolution of 400 pixels per inch (dpi). That will yield acceptable quality if an employee wants prints to insert in his personal scrapbook. It will also display well on a computer screen, which helps a supervisor doing performance reviews. But it won't result in big files--which can bog down a computer when a PowerPoint file gets up to 200 frames or so. Save the files in TIF format, with LZW compression turned on.

You can use your choice of software to control the scanner and manipulate the files, although PowerPoint has some tools of its own for cropping, scaling and adjusting scanned images. Photoshop is probably the best choice for manipulating images. The full package is pricey, but it's capable of scanning as many forms at a time as you like on a Mac or PC, subject to the limitations of your computer. My agency, Pridemark, uses it to process about 30 forms a week, and it has ample power to handle two or three times that many in case the feedback person goes on vacation or something. We have had less experience with Corel PhotoPaint, a similar program with an excellent reputation and a smaller price tag.

Fair and attributable, but negative comments on forms should be included in employees' PowerPoint files as well, but only after an investigation that incorporates employee input. These always warrant private discussions between supervisors and employees, and should never be posted.

It's hard to go wrong if you treat your people with respect, and if you consistently praise them in public and criticize them in private.

Honest Respect

Fielding complaints is a lot like rendering care if you consider that in either case someone is in crisis. People in crisis are very good at determining who's on their side and who's not. If you don't honestly respect them and their situation, no amount of fakery on your part will fool them. In fact, respect for people is probably the most critical attribute of anyone who handles complaints--even more important than communication skills.

Active Listening

There's a big difference between hearing and listening. Hearing is not necessarily something you do on purpose. For instance, when you hear the background music at Starbucks, you don't necessarily pay much attention to it. On the other hand, if you're sitting there with someone and you don't listen to what they're trying to tell you, they're likely to start banging on the table.

There's also a big difference between listening and just waiting for your turn to talk. When a complainant tells you that a paramedic was rude, listen with your whole body--for instance, your ears, your facial expression, your eyes, your posture and maybe a note pad. Convince the complainant that you are not just hearing them, but that you're honestly dialed in to what they're saying.

Make it your goal to elicit the caller's "chief complaint" in the first minute of your contact with them--just as you would on a medical call. Are they upset about your agency's response time, a caregiver's attitude, an invoice or maybe a long wait in the ED while they laid on your backboard? Some people are not very good communicators, especially when they're upset. But knowing the chief complaint helps you to understand the rest of what a caller has to say.

Also in the first minute, try to determine the intensity, or "acuity," of the complaint. Is it a passing FYI, or is it driving them nuts? If the essence of the feedback is a complaint about abuse of a patient, that warrants a brief discussion by phone, then an immediate personal visit from a mid-level manager or better. If it's about a patient who can't find her watch, that still warrants immediate action, but it's not as serious. Respect the fact that lost items become harder to locate with every minute that goes by. (Chances are, that kind of complaint does not involve a major breach of patient trust unless it's part of a pattern involving a specific employee.)

Another way to think of acuity is to consider how much effort someone expends to tell you what they want you to know. Unlike the medical kind of acuity, that can be either good or bad. For instance, do they write you a long letter, or do they simply fill in the check boxes on your feedback form and toss it in the mail? A letter always means more than a few check marks. So does a stand-alone thank-you card, and so does an angry phone call. Likewise, a thoughtful compliment that accompanies a payment for service is especially meaningful.

If you're taking a complaint by phone, make sure the door to your office is closed. In fact, consider making a point of that. It helps a complainant to know you're paying attention if you ask their permission to place them on hold for a moment while you close the door. When you get back on the phone, turn on your little digital recorder, switch the phone to speaker mode, and then ask the complainant if it's all right to record their conversation. If they say no, at least consider the possibility that the complaint is bogus. If they say yes, record the entire conversation, including a momentary audio documentation of the time, date and complainant's name and address. If possible, turn off the ringer on your phone so you're not distracted by an incoming call.

Try never to interrupt a complainant, especially one who's trying to answer a question you've just asked. You've seen what happens when a paramedic questions a patient about a complaint, then interrupts before the patient has time to finish answering. Well, complainants are in crisis just like patients are (only complainants are seldom short of breath).

When you do contact a complainant, be sure to acknowledge your realization that they are just as busy as you are and have better things to do than spend time on the phone with you.

EMS consultant and expert communicator Mike Taigman offers a questioner the following suggestion: Wait two full seconds after someone appears to be finished talking, then address their comment or question. That tells the person you're talking to that you've been listening to them. It also gives you a moment to think of an answer.

Speaking of answers, you should feel compelled to respond to every message from a complainant as soon as possible. Set a goal for your organization of contacting every complainant within five minutes of becoming aware of a complaint. That's an unmistakable sign of respect. And if anyone in your organization becomes aware that they are dealing with a complaint, make it their goal to personally connect the complainant with someone who has the authority to resolve their complaint on the spot. We're all human, so that's not always possible. But think about this. All we do for a living is serve people. When a customer makes us aware that we've done that poorly, they expect us to be concerned about it.

At least one of the world's biggest airlines has a reputation for overbooking seats and then canceling your ride when you arrive at their gates. If you've ever had that happen to you, you know how frustrating it can be. It's such a routine part of their performance, they leave it up to their low-ranking gate staff to break the news to you. And the gate staff are so used to dissatisfied customers that when you express your frustration, they just give you a practiced 20-mile stare. It should come as no surprise to them that their company is in danger of collapsing.

Consider that 20-mile stare for a moment, and think about how important it is to empower your crews to take some action on a complainant's behalf. You should devise your own policy, but a good one would be to authorize them to write off at least part of a patient's bill for service on the spot if they think the service was substandard. The world of EMS billing is not a simple one. But if a crew can handle the responsibility for a patient's physical well-being, they're surely competent to recognize and compensate for bad service.

Confronting the Unhappy Caller

Aside from the fact that every caller deserves a prompt reply, a lack of responsiveness will tell them you don't care (whether that's true or not) and give them time to brood. Depending on a variety of unknowns, including how angry they are, they could get angrier and angrier. They may decide to take their complaint to an attorney, to your local civic officials or to the media. You don't want any of those things to happen, even if you know you will eventually be exonerated. It's costly, it's embarrassing for your people and it's easily preventable.

Feeling nervous about calling a complainant? That's normal. Nobody enjoys having their work called ugly. But try thinking of that call as an effort that may save the good names of your people and your organization in the mind of the complainant.

Of course, some complainants can't be "saved," any more than some patients in cardiac arrest. But often, they're as easy to "resuscitate" as a patient with a witnessed onset of coarse V-fib. The complainant may have simply misunderstood a procedure that you can clear up with a single phone call. Or, they may point something out to you that your agency really needs to know about itself. Their concern may be so completely rational that you find yourself agreeing with them. And occasionally, they may be simply implacable--an RNP, or really nasty person. In those cases, nothing you can say or do will produce a state of emotional balance in them that may never have been there in the first place.

Sometimes the best you can do is the best you can do. Most city councils understand that, and they know you're bound to get some complaints. But if you can document that your agency consistently acts promptly and aggressively when you identify an unhappy customer, you'll make yourself (and them) look as good as possible over time.

Fortunately, most complainants are reasonable when they find out you honestly care about their concerns. Also, most understand that responding and having answers are two different things. When someone (like a field leader) responds to a complainant, that stops the caller's mental clock and gives you time to investigate. Tell the complainant truthfully that you called as soon as you received their message. Apologize for their unhappiness, but don't accept responsibility for anything on the part of the crew or your agency, just yet. Tell the caller you will investigate the matter right away and offer a realistic time frame to get back to them.

Why not accept responsibility? Your crew may have a very good explanation for whatever produced the caller's complaint. In fact, experience has shown that is almost always true--unless you're dealing with an angry workforce. Accepting blame on the crews' behalf is an indictment of them based on nothing more than an allegation. And many complaints are simply unfair, or are not the crews' fault. Remember, you have a critical responsibility to protect that crew and you jeopardize them anytime you fail to presume their innocence.

Getting back to a complainant has another benefit. It gives you time to think about their complaint, consider how to respond, and possibly consult a superior for input.

When you promise to contact a complainant, do that--every time. Should you offer to meet with them personally? That depends on how busy you are and how serious the complaint is. A personal meeting makes good sense when the complainant alleges patient abuse or damage of some kind, like to a residence or a vehicle. (That way you can videotape or photograph the damage.) It also makes sense when the chart doesn't bear out the complaint, or when the crew's story differs radically from the complainant's account of what happened. Confronting someone face-to-face, even politely, suggests your credibility and your interest in the truth. It can also cause bogus complaints to evaporate.

If there is damage and the complainant says it was caused by a piece of equipment (like an ambulance), arrange to bring the equipment with you and have the complainant walk you through what happened. You should take photos, and they should be sharp. A digital camera might be preferable because it minimizes the chances of needing to return because the photos didn't turn out well. However, you should only use one with a quality of four megapixels or more. That resolution will yield a 5" x 7" photo at a resolution of 300 dpi, which is good enough for many uses--including legal testimony. Photos are also good educational tools, long after complaints have been resolved.

Simply asking the complainant to demonstrate how damage occurred with the equipment right there can exonerate your crew on the spot. The photos can serve as proof, and a digital voice recording early in the investigation helps you to protect your crew from "accusational drift"--a change in the original complaint.

But make no mistake. The idea of a good investigation is not to prove that the complainant is a bogey. It's to get at the truth, and nothing but.

Pre-empting Complaints

It would be a serious mistake not to involve your field crews in the process of resolving complaints. When an EMT or paramedic becomes aware that a customer is unhappy with your agency's service, he or she should feel welcome to bring that concern to you. You can then contact the customer before they get a chance to complain, listen to what they have to say, and resolve the issue before it has a chance to grow a life of its own. If you substantiate the complaint, adjust any applicable charges accordingly. Then, be sure to thank the crew for their help.

Teaching with Feedback

Always be alert for complaints that might serve as object lessons. For example, the complaint might be that your crew failed to provide blankets in cold weather. You know that if you talk to people about that, they eventually get tired of hearing it. They're not perfect, any more than you are. Sometimes, they simply forget. But try this:

Ask the complainant to repeat the basic gist of their complaint, so you can record it for training purposes. (You can embed a recording like that into a PowerPoint frame or even a Word document.) Tell them how much impact their voice can have on a room full of EMTs and paramedics compared to yours. That technique has turned many an angry caller into a fan of an EMS system, because it channels their anger into positive action--and it convinces them that their concerns really matter.

Where Does It All Go?

There would be no benefit in feedback that never went anywhere. Don't just process your complaints and file them away. In addition to the documentation on digital recorders and cameras, scans and transcriptions of investigation notes and other documents (including refusal forms, PCRs and dispatch records) can all be stored and circulated monthly to field leaders on CD or DVD. A single CD can accommodate more than two years' worth of feedback (both positive and negative) for a workforce of 230 people. That includes all pertinent sound files, photos and scans.

Anonymous audio recordings and photos can easily be inserted in PowerPoint files for training purposes. In addition, the use of crews' names is a powerful illustrator of exemplary care, as long as everyone in your organization knows they are safe from negative public comments under any circumstances.

The crews themselves should feel welcome to access their files anytime.

Most important, make sure your service responds internally to the complaints it receives. Think of your customers as consultants who pay your agency for the distinction of sharing their advice with you. You should benefit from their observations, and understand the positive and negative behaviors that generate them.

You'd be silly not to, don't you think?