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The client as customer: achieving service quality and customer satisfaction in rehabilitation.

Rehabilitation, both public and private sector, is part of the service industry, which employs seven of ten people and generates nearly 70% of the gross national product in the United States (Cina, 1989). Faced with rising prices and increased competition, the service industry in general has adopted marketing concepts, which traditionally have been associated with the goods industry. Two focal points in marketing for the organizations that comprise the service sector are service quality and customer satisfaction.

In business, extensive research on service quality and consumer satisfaction has been conducted during the past 15 years (Uhl & Upah, 1983) to enhance marketing efforts. Although rehabilitation is part of the service industry, the research on consumer satisfaction with rehabilitation services is more limited (e.g., Rubin, 1975) and has been primarily restricted to vocational evaluation services (e.g., Early & Bordieri, 1988; Janikowski, Bordieri, & Musgrave, 1991). Although Cook (1977), as well as Patterson and Leach (1987) specifically addressed the importance of consumer satisfaction in rehabilitation, most articles (e.g., Banja, 1990; Megivern, 1991) more indirectly address this issue in their discussions of advocacy, empowerment, partnerships (Howe, Minch, & Fay, 1980), consumer involvement (Department of Education, 1990), self-determinism (Department of Education, 1985) and self-management (Sawyer & Crimando, 1984). Consumer satisfaction encompasses more than these areas, however, and some rehabilitation consumers have expressed dissatisfaction with rehabilitation.

An illustrative example is the rehabilitation consumer publication, This Brain has a Mouth, which clearly expresses consumer dissatisfaction with rehabilitation services and rehabilitation professionals. The cover of a recent issue (May/June 1991) titled "How to promote your client to customer" highlights the need for service quality and consumer satisfaction to be more effectively addressed in rehabilitation and also supports Boynton and Fair's (1986) contention that:

Rehabilitation providers have traditionally been product-driven. That is to say, they have created programs and services using the expertise of professionals regardless of the needs and wishes of the consumers. (p. 174)

The purpose of this article is to review the business literature on services marketing that is directly relevant to the achievement of service quality and customer satisfaction in the delivery of rehabilitation services. Characteristics of services, determinants of service quality, and the differences between professional and generic services are defined, and direct implications for rehabilitation professionals are discussed. An important consideration in applying the general business services marketing literature to rehabilitation is the difference between client and customer.

Client vs. Customer

One major difference between private industry and the public service sector is the terminology used to identify the consumer of services. In private industry, consumers are referred to as customers. However in the public sector, consumers are usually referred to as clients. Although the differences may be viewed as "professional semantics," Webster's (1985) definitions of the two do not support this view. Client has been defined as "one that is under the protection of another: Dependent" or "a person who engages the professional advice or services of another (lawyer)" or "a person served by or utilizing the services of a social agency (welfare)" (p. 248). In contrast, customer is defined as "one that purchases a commodity or service" (p. 318).

It is evident in these definitions that the term client conveys an image of an active professional in a paternalistic role and a passive consumer, whereas the term customer conveys an image of an active consumer selecting or purchasing a service or product. The active vs. passive difference can also be noted in the definitions of good customers and good clients. Good customers are individuals who (a) spend money, (b) always return, (c) recommend product/service to others, (d) know what they want, and (e) provide feedback. In contrast, good clients are frequently viewed as individuals who (a) keep appointments, (b) are motivated, and (c) do what they are told to do.

The professional literature for individuals serving customers and clients also suggests differences. The Journal of Services Marketing contains titles such as "Who is your satisfied customer?" (Hanna & Wagle, 1988), "Creating an effective customer satisfaction program" (Cina, 1989), and "Focusing on customer problems to improve service quality" (Brandt & Reffett, 1989). None of these are common topics in the rehabilitation literature.

Lastly, there is no parallel phrase for "the customer is always right" in social service agencies. In fact, social service agencies have questioned "the credibility of clients' perceptions" (Patterson & Leach, 1987), since it is "the professional prerogative to prescribe needed services, even when ... |people with disabilities~ do not believe they need them" (Stubbins, 1984, p. 198).

It is evident that different images or even stereotypes are conveyed by the terms client and customer. It appears that the term client may be changing to a stereotypical term as a result of the evolutionary nature of language related to disabilities described by Burgdorf (1980):

The development of terminology applied to handicaps has tended to follow an evolutionary pattern. New terms are selected, generally from medical or social science, to describe a particular condition... The new term is introduced into the vocabulary of leading professionals and gradually is absorbed into general usage. Over the course of many years, the term becomes associated with social stereotypes and acquires derogatory connotations. Eventually it is replaced by a new term, which does not yet have any negative implications, and the process begins all over again. (p. 46)

There is no evidence that "client" has become a pejorative term in the same way "the disabled" has (see Boland, 1980, LaForge, 1991; Patterson, 1988), nor is there research to support different beliefs and behaviors toward individuals who are labeled client, rather than consumer or customer. Mental imagery and common sense, however, suggest different roles and expectations on the part of service providers. Therefore, considering clients as customers may require rehabilitation professionals to reexamine their philosophy of rehabilitation, as well as their practices.

The philosophy of rehabilitation encompasses beliefs related to dignity, self-worth, integration, self-determination, advocacy, empowerment, and autonomy (Banja, 1980; Bitter, 1970; DeJong, 1979; Maki & Riggar, 1985; Noble & McCarthy, 1988; Nosek, 1988; Wright, 1983). Although the term client may have encompassed this philosophy at one time, it is evident that the philosophy of rehabilitation is presently more accurately conveyed in the word customer. Moreover, because of the differences between what people believe and what they say and do on the basis of their beliefs (Van Hoose & Kottler, 1985), professional practices should also be reviewed. In order to evaluate professional practices, it is helpful to consider the definitions of service quality and customer satisfaction.

Service Quality and Customer Satisfaction

Service quality and customer satisfaction have both been defined as matching the expectation of the service with that which is actually experienced by the customer (Cina, 1989; Lewis & Booms, 1983). Therefore, when customers' experiences meet or exceed their expectations, the service is viewed as a quality service and the recipients are typically satisfied customers. Conversely, when the service experienced by consumers is less than their expectations, the perception of service quality is diminished and customers are generally not satisfied. Because of the following characteristics of services, quality evaluations are made on both the process, as well as the outcome of service delivery (Parasuraman, Zeithaml, & Berry, 1985).

Characteristics of Services

Hill and Neeley (1988) defined services as "that broad class of products characterized by intangibility, inseparability of production and consumption, difficulty of standardization and perishability" (p. 17). These four unique characteristics of services, which also apply to rehabilitation services, make evaluating customer satisfaction with services different from evaluating satisfaction with goods (e.g., computers, automobiles, clothing).

1. Intangibility refers to a lack of physical properties and the inability to touch, feel, store, readily display, or easily communicate services (Parasuraman & Varadarajan, 1988; Uhl & Upah, 1983). A rehabilitation service is intangible, even if it results in a product (e.g., psychological report, Individualized Written Rehabilitation Program).

2. Heterogeneity refers to variability, inconsistent behavior and a lack of uniform quality in service delivery (Booms & Bitner, 1981). Parasuraman and Varadarajan (1988) noted that "since most services are people-based, a major problem in the service sector is variation in the quality and content of services delivered by different employees, and by the same employee at different times" (p. 64) and "what the firm intends to deliver may be entirely different from what the consumer receives" (Parasuraman et al., 1985, p. 42).

3. Inseparability of production and consumption refers to the fact that the consumer not only uses the services, but participates in various ways with the production of the service. There is a required interaction between the customer and service provider (Carmen & Langeard, 1980), which in the case of some services (e.g., medical services, health services) may be "critical to the quality of service performance" (Parasuraman et al., 1985, p. 42).

4. Perishability refers to the inability to inventory services (Parasuraman & Varadarajan, 1988). Office supplies can be periodically inventoried; however, the nature of social services precludes counting the number of services remaining.

These characteristics make it more difficult for both service providers and consumers to evaluate the quality of a service. Despite this difficulty, various determinants of service quality have been identified.

Determinants of Service Quality

Parasuraman et al. (1985) identified the following 10 determinants of service quality:

Reliability involves consistency of performance and dependability...

Responsiveness concerns the willingness or readiness of employees to provide services. It involves timeliness of service...

Competence means possession of the required skills and knowledge to perform the service...

Access involves approachability and ease of contact...

Courtesy involves politeness, respect, consideration, friendliness of contact personnel (including receptionists, telephone operators, etc.)...

Communication means keeping customers informed in language they can understand and listening to them. It may mean that the company has to adjust its language for different consumers...

Credibility involves trustworthiness, believability, honesty....

Security is the freedom from danger, risk or doubt....

Understanding/Knowing the Customer involves making the effort to understand the customer's needs...

Tangibles include the physical evidence of the service... (p. 47)

According to the model developed by Parasuraman et al. (1985), these 10 characteristics of service quality contribute to both the expectations of the service to be provided, as well evaluations of the service when it is received.

In considering the determinants of service quality, it is clear that the characteristics of services influence perceptions of quality by consumers. For example, because services are intangible, greater emphasis is placed on physical facilities, appearance, and staff and service providers themselves.

Generic vs. Professional Services

Within the service industry, a number of authors have also identified differences between generic and professional services (Bloom, 1984; Hill & Neeley, 1988; Webster, 1988). Professional services are specialized services in which:

Professionals possess expertise developed through formal higher educational preparation and exercise expert judgment in delivering the service...professionals have a recognized group identity, are largely self-regulatory, and historically have not perceived themselves to be sales and market oriented. (Hill & Neeley, 1988, p. 18)

Professional services are characterized by higher consumer involvement (Webster, 1988) and greater consumer uncertainty (Bloom, 1984) in the decision process.

Features of professional services that contribute to uncertainty include (a) lack of standardization, because the customer provides critical information to the professional in order for the professional to assess the situation and define the problem (e.g., telling the doctor where one hurts or telling a rehabilitation counselor about one's interests); (b) infrequent use of professional services and insufficient and/or unavailable information on services, which create difficulties in determining alternative service providers and their qualifications and forces heavy reliance on information from a limited number of other people (i.e., word of mouth); and (c) evaluation of services during and after the provision of services (Hill & Neeley, 1988). The evaluation of professional services is especially troublesome for consumers, because "it may be impossible to precisely determine whether the problem was solved correctly," "the inability or undesirability of having the service redone" or reversed, and "the individual has even less confidence in his or her ability to make a better choice the second time" (Hill & Neeley, 1988, p. 21).

The differences between generic and professional services clearly indicate that rehabilitation services are professional services. As such, specific strategies can be utilized by rehabilitation agencies and facilities to promote customer satisfaction.

Improving Service Quality and Customer Satisfaction - Implications for Rehabilitation

By attending to the characteristics of services, the determinants of service quality, and the differences between generic and professional services, the rehabilitation professional can become aware of a number of areas to improve service quality and customer satisfaction. Enhancing the satisfaction of each customer is the responsibility of all personnel employed in rehabilitation agencies and facilities. As Cina (1989) noted, "quality is defined by a company's customers and created by its employees" (p. 6).

The 10 determinants of service quality outlined by Parasuraman et al. (1985) provide a logical approach to assessing service quality. Every rehabilitation employee from support staff to top management should determine the current status of and ways to make improvements in each of the 10 areas. Some examples may suggest ways to apply each of these components to rehabilitation.

* Reliability. Crosby, Evans, and Cowles (1990) indicated that "the customer's best assurance of future performance is a continuous history of personalized, error-free interaction" (p. 70). Furthermore, anticipated levels of satisfaction influence a consumer's decision to continue with a service (Jackson, 1985). Thus, being able to anticipate that dependable services experienced in the past will continue into the future helps to ensure a customer's happiness with the service. In this way, providing consistently reliable services constitutes a formidable challenge to rehabilitation professionals. Moreover, due to customer differences, rehabilitation professionals have to promote reliability on an individualized basis. In a broad sense, one way to enhance the consumer's experience of reliability is to do what you say you will do and expedite the rehabilitation process (e.g., completing paperwork in a timely manner).

* Responsiveness. Related to expediting the rehabilitation process, responsiveness requires awareness of the customer's needs, desires, and difficulties. Returning phone calls, being on time for appointments, and being willing to do a little something "extra" for the customer are all part of responsiveness.

* Competence. According to Hill, Garner, and Hanna (1989), "competence is the most important selection criterion for professional services" (p. 62). In their investigation of the selection criteria for professional service providers, they found that 80% of the respondents rated knowledge as one of the five most important criteria. Other behaviors that translated into competence by consumers in rank order included (a) acting interested in the problem, (b) explaining actions, (c) asking appropriate questions, (d) offering practical solutions, and (e) spending enough time with the consumer (Hill, Garner, & Hanna, 1989). Because competence is intangible, however, it is one of the most difficult determinants of service quality for customers to evaluate (Parasuraman, Zeithaml, & Berry, 1985). Therefore, the customer may rely on other determinants of service quality that are easier to judge.

* Access. Accessibility involves more than making one's agency or organization accessible to individuals with disabilities. Being able to get a counselor on the phone, ease in scheduling appointments, and comfort in interpersonal contact with agency or organization personnel are all ways that a customer might appraise access.

* Courtesy. This is an area that is important for all levels of an organization to address, because of those "critical moments of truth--those occasions when customers and employees come into contact with one another, providing the employee an opportunity to form a favorable, long-lasting impression" (Cina, 1989, p. 8). In rehabilitation, a critical moment of truth frequently begins with the receptionist or secretary. Such support personnel can do much to ensure that the customer feels services are of a high quality. Because customers frequently have no clear basis to evaluate some aspects of service quality (e.g., competence), determinants of service quality that can readily be judged, such as courtesy, take on increased importance.

* Communication. Consumers need information to understand the rehabilitation process and make informed decisions. Webster (1988) said, "communications should be available and should be extremely informative, with information on the service provided as well as on the characteristics of the provider" (p. 65). Hill and Neeley (1988) supported these recommendations and included the development of videos, as well as brochures, to explain the service and possible outcomes. Research suggests that communication is another highly rated factor that customers use when selecting professional services. Hill, Garner, and Hanna (1989) found that three of the top five selection criteria related to communication (e.g., asking questions, explaining actions, offering solutions/alternatives). Research on dissatisfaction with services suggests that the way communication occurs is as important as the content of what is said. Quelch and Ash (1981) found that services provided in a "careless, impersonal manner" was the most frequently cited problem by consumers of professional services. The importance of communication highlights the need for rehabilitation professionals to have excellent counseling and interpersonal skills.

* Credibility. The agency name and reputation, positive word of mouth, and visibility in the community form part of an organization's "social reputation" (Hill, Garner, & Hanna, 1989). Although Hill, Garner, and Hanna (1989) found that theoretically such factors were not the most important influences in the selection of professional services, in practice they often become more influential as customers have few concrete ways to judge the more intangible features of services (e.g., knowledge, competence). Thus, when unable to tell if a professional or agency is doing a good job, the customer will, instead, rely on credibility factors.

* Security. Professional services often represent a high risk to consumers. Not only might consumers of rehabilitation services depend on service personnel for future financial security, there is also a potential for social stigma connected with procuring services (Quelch & Ash, 1981). Features of security such as confidentiality may assume higher importance because of this. It is important for service providers to understand risks as they are perceived by consumers (e.g., loss of benefits, family support), openly discuss the risks (Hill & Neeley, 1988), and provide "redress procedures". Although most rehabilitation agencies publicly display information on Client Assistance Programs, openly discussing these with consumers may decrease feelings of risk and increase their feelings of security.

* Understanding and Knowing the Customer. This is undoubtedly one of the most critical determinants of service quality. Therefore, methods to obtain and continuously update this knowledge are critical. Brandt (1988) stated that "the basic goal of any customer satisfaction measurement program is to provide a formal system for monitoring customer opinions and perceptions about the quality of a company's goods and/or services" (p. 37). Cina (1989) recommended using focus groups as a qualitative, rather than quantitative, measure of service quality as well as customer satisfaction surveys. He also stressed the importance of both service provider and customer completing customer satisfaction surveys: "Ideally, frontline employees' perceptions of what is important to the customer should match the customers' perceptions" (Cina, 1989, p. 9).

Keiser (1988) stated that organizations need to be continually reminded of the customer's perspective. He also recommended:

helping employees who have regular contact with customers to step back from their daily routine to reflect on ways to better serve the customer. It also means helping the people in the "back office" who rarely, if ever, see the customer to understand how they add value for the customer (p. 67). Understanding and knowing the customer can also prevent rehabilitation agencies/facilities from committing a common error identified by Garvin (1987), "introducing dimensions of quality that are unimportant to consumers" (p. 109).

In professional services, consumers should be involved as much as possible. In fact, Hill and Neeley (1988) recommended increasing "the consumer's control of the decision process" by involving consumers in both the "initial stages of service design" as well as in "aspects of service delivery and post service requirements" (p. 21). Although this is legislated as part of the rehabilitation process (i.e. Individualized Written Rehabilitation Program), the degree of involvement certainly varies in rehabilitation.

Consumer education is another method that facilitates consumer involvement and encourages customers to become active participants, rather than passive recipients, of a service (Goodwin, 1988). Recognizing the importance of consumer participation in certain services and believing that "role awareness may occur whenever a consumer utilizes a new service," Goodwin (1988, p. 72) suggested that consumers must (a) learn new skills, (b) develop new self-images, (c) develop new relationships, and (d) acquire and understand the agency/facility values. She noted that providing information and teaching skills may be insufficient to overcome consumer identity issues. This concept is not new to rehabilitation; however, it is not always applied in the desired direction. Pimentel (1984) provided an example of an assertive consumer who had to overcome her assertiveness and demonstrate "learned helplessness" in order to receive the desired services from a rehabilitation agency.

* Tangibles. Although characteristics such as credibility and knowledge may be very difficult for a consumer to evaluate, tangibles are clearly visible and understandable, and may serve to help the customer form an initial impression or make quality judgements in the absence of other concrete indications of quality. Tangibles can include the way the physical environment looks (e.g., decor of waiting area, cleanliness, parking facilities), and the appearance of direct contact personnel. Attention to neatness and personal touches in offices can help people have more positive judgements about service providers.

Summary

When clients are viewed as customers, service quality and customer satisfaction are critical factors in the delivery of rehabilitation services. Service providers can provide better services when they seek feedback and listen to the views of the consumers.

Understanding the differences between goods and services, the determinants of service quality, and the differences between generic and professional services can help rehabilitation agencies/facilities better assess service quality. Our goal in rehabilitation is to meet and hopefully, to exceed the expectations of the consumers we serve.

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Author:Marks, Cindy
Publication:The Journal of Rehabilitation
Date:Oct 1, 1992
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