From Customer Satisfaction to Customer Bliss

Optimizing Your Customers Experience

Sergei Kochkin, Ph.D. Better Hearing Institute

Topics to be Covered
Defining

consumer satisfaction of consumer satisfaction

Importance What's Actions

important to the end user to improve customer satisfaction

What is customer satisfaction & what is benefit?

Defining Customer Satisfaction

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.

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

Some Synonyms for Satisfaction

Adequacy Adequacy Acceptability Acceptability Comfort Comfort Fulfillment Fulfillment Serenity Serenity Peace of mind Peace of mind Keen pleasure Keen pleasure Cloud nine Cloud nine

Happiness Happiness
Gladness Gladness

Agreeability Agreeability Sufficiency Sufficiency

Gratification Gratification Contentment Delight Contentment Delight Euphoria Euphoria Elation Elation Rapture Rapture

Well being Well being Amusement Amusement Relief Relief Cheer Cheer

Ecstasy Ecstasy Bliss Bliss Exhilaration Exhilaration Heaven Heaven

What is Customer Satisfaction?

Whatever The

the customer says it is.

extent to which hearing aid benefit meets consumer needs. definition (Vanderbilt Report II):

Clinical

"a change between unaided and aided speech communication ability"

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

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.

Importance of Customer Satisfaction

Business is made up of the largest group of volunteers in the world......customers!

Consumer Satisfaction is Important to Health of Hearing Aid Industry

Would you repurchase brand of hearing aid?

Consumer Satisfaction is Important to Health of Hearing Aid Industry

Would you recommend hearing aids to your friends?

Consumer Satisfaction is Important to Health of Hearing Aid Industry

Would you recommend the dispenser who fit Your H.A.?

Reasons for Non-purchase of Hearing Instruments

$19 billion dollar loss to audiologists & dispensers

Impact of Dissatisfied Customers

Deming

proved that a dissatisfied customer tells 16 other people but a satisfied person only 8 others. word-of-mouth has blocked close to 4 million from purchasing our product in the U.S. $19 billion loss to dispensers.

Negative

Potential

Impact of Customer Dissatisfaction

No No

initial sale of the product repeat purchase of the product word-of-mouth advertising

Negative Less More

referral business
bad debt write-offs

Impact of Customer Dissatisfaction

Higher
Lower Lower More

employee turnover & absenteeism

staff morale compliance with instructions

malpractice suits

Lower

profitability

What Customers Want

Relative Importance of Factors on Overall Consumer Satisfaction

Top 4 explain 96% of variance in overall satisfaction.

Impact of Improving Multiple Environmental Listening Utility (MELU) on Overall Satisfaction

(All hearing aid owners n=2,572)

100 90 80 70 60 50 40 30 20 10 0

78 77 66 51 37 27 18 19 9 0 1 2 3 4 5 6 7 8 9 58 56

82

89 90 89

% Satisfaction

10 11 12 13 14

Number of Listening Situations Satisfied

Relative Importance of Factors on Overall Consumer Satisfaction

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.

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

Factors Most Related to Overall Customer Satisfaction

Benefit at a good value Better sound quality Better Reliability Multiple Environmental Listening Utility (MELU)

Hearing Aid Improvements Sought by Current Hearing Aid Owners (n=2,428)

(Highly desirable scores =4-5 on 5 point scale)

Speech in noise Better sound quality Less whistle/buzzing Lower price More soft sounds Longer lasting batteries Work better on telephone Loud sounds less painful Speech in quiet Better fit & comfort Should have VC Longer money back guarantee Less costly to repair
0 10 20 30

95 88 85 84 83 82 82 81 81 79 77 74 73 40 50 60 70 80 90 100

% highly desirable

Hearing Aid Improvements Sought by Current Hearing Aid Owners (n=2,428)

(Desirable scores =4-5 on 5 point scale)

72 Easier to regulate volume 71 Mask tinnitus 66 Easier to clean 63 Work better on cell phone 62 Better sound to music 56 Should not break down as much 52 Less visibility 48 Easier battery change 34 2-5 year payment plan 32 Should have remote 28 More fashionable 21 Color Lease hearing aid 15 0 10 20 30 40 50 60 70 80 90 100

% highly desirable

Improvements Sought in Hearing Instruments

Speech

intelligibility in noise Better sound quality Less whistling & buzzing (feedback) Lower price More soft sounds audible

Why My Hearing Aids

The Consumers Perspective:

Are in the Drawer

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%

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.

Hearing Aids in the Drawer are Related to Age of the Instrument

But a third are New Hearing Instruments

325,000 1-4 years

120 100

Volume (000)

80 60 40 20 0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Age of hearing aid (years)

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

Reasons for Non-Use

Poor

benefit (30%) - 268,507

Reasons for Non-Use

Poor Benefit

I threw it away it was worthless to me I dont see much difference with them. I feel I was sold one under false pretense. Dont 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.

Reasons for Non-Use

Poor Benefit

I dont wear the aids at all. The problems appears to be clarity of words. Volume is OK but I cant 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.

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 peoples money for little value. All the aids do is amplify the sound that I cant discriminate with an aid in the ear.

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 dont 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.

Reasons for Non-Use

Poor Benefit

I cant 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.

Reasons for Non-Use

#1. Poor benefit (30%) - 268,507 #2. Background noise (25%) - 229,383

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.

Reasons for Non-Use

Background Noise

H.A.s dont 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.

Reasons for Non-Use

Background Noise

I dont 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.

Reasons for Non-Use

Background Noise

If someone drops a spoon on the table it is like a rifle going off. Hate them. They dont work for me. All sounds are amplified. Never knew there were so many. I cant adjust the H.A. constantly to every noise.

Reasons for Non-Use

#1.

Poor benefit (30%) - 268,507 #2. Background noise (25%) - 229,383

#3. Fit & Comfort (19%) - 169,431

Reasons for Non-Use

Fit & Comfort

My hearing aids are too big for my ears. It is uncomfortable and my wife says I dont listen to her anyway. It hurts my ears. I do not like the feel of it in my ear.

Reasons for Non-Use

Fit & Comfort

I dont 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. Its hard to keep it in my ear. I travel for business a lot and cant risk it falling out of my ear.

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

Negative Side-effects
Ears

Reasons for Non-Use

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

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

#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

#5. Price & cost (10%) - 93,839

Reasons for Non-Use

Price & Cost

I bought the H.A. when I was teaching. I had trouble hearing students 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.

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.

Reasons for Non-Use

Price & Cost

I enjoyed my H.A., but they burned up in a house fire and I cant 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.

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.

Minor Reasons for Non-Use

#6.

Dont need help (8%) - 72,987 #7. Broke or does not work (8%) - 68,814 #8. Sound quality (6%) - 57,329 #9. Wont 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

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

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

Key Findings
907k

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

Key

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.

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

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.

What Can the Industry Do to Improve Customer Satisfaction?

Customer Satisfaction is a Complex Issue

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

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

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.

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

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

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

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

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.

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

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

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)

Typical Usage Satisfaction by Generic Feature

(Composite score: overall, value, sound quality, 1-on-1, reliability, perceived benefit)

N.S.

Multi-environmental Value Satisfaction by Generic Feature

(Composite score: 9 listening situations, noise, directionality)

N.S. N.S.

Total Subjective Benefit by Generic Feature

(Composite APHAB score: EC, BN, RV)

N.S.

N.S.

Satisfaction by Technology on Overall Satisfaction

64 69

Overall

76 79 90

78 78

Improves hearing

83 87 95

Type of hearing aid MarkeTrak (Av erage) 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 WDRC - CIC Percent satisfied Single Channel/Memory Prog. Multiple M emory/Channel Prog. Multiple M emory/Microphone Prog.

Satisfaction by Technology on Sound Quality

61 62 67 74 83 56 63 66 70 74 40 61 47

Sound quality

Natural sounding

Whistling/feedback

61 Type of hearing aid 65 MarkeTrak (Av erage) WDRC - CIC 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 Single Channel/Memory Prog. Percent satisfied Multiple M emory/Channel Prog. Multiple M emory/Microphone Prog.

Satisfaction in Difficult Listening Situations by Technology

56 69 61 61 67 56 71 61 66 67 55 54 54 57 67 30 40 50 60 70 80 90 100

Place of worship

Outdoors

Car
Type of hearing aid MarkeTrak (Av erage) WDRC - CIC 0 10 20 Single Channel/Memory Prog. Multiple M emory/Channel Prog. Multiple M emory/Microphone Prog.

Percent satisfied

Satisfaction in Difficult Listening Situations by Technology

45 49 45 42 67 34 58 40 43 45 26 34 26 27 51 Type of hearing aid MarkeTrak (Av erage) WDRC - CIC Single Channel/M emory Prog. Multiple Memory/Channel Prog. Multiple Memory/M icrophone Prog.

Restaurant

Telephone

Large Group

10

20

30

40

50

60

70

80

90

100

Percent satisfied

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

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

Omni versus Directional Hearing Instruments

MarkeTrak VI (October 2002 HR)

Customer Satisfaction Improvements of at Least 15% Due to Dual-microphone (Directional) Technology

(H.I. < 6 years of age)

Summary of Impact of Directional Microphones on Customer Satisfaction

Omni-directional programmable vs non-programmable Overall satisfaction Factors - 20% improvement Factors - 15% improvement Factors - 10% improvement 7% 0 0 2 Directional (dual mic) vs omnidirectional 17% 3 17 33

Top 10 factor improvement

Net listening situations imp. Net perf/value factors imp. Net total differences

5
6 8 27

10
12 11 42

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 45 ratings of hearing aid and dispenser

Consumer completed MarkeTrak survey

Overall, Consumer Behavior & Dispenser

Factor
Single Mic & MarkeTrak Multiple Mic & Multiple mic MarkeTrak & Single Mic

Significant Differences

Overall satisfaction Quality of life Recommend HA Recommend HHP Repurchase HA Wear hearing aid Dispenser service

Significant Differences

Product Features
Single Mic & MarkeTrak

Factor

Multiple Mic & Multiple mic MarkeTrak & Single Mic

Fit/comfort Ease VC adjust. Visibility Packaging Freq. Cleaning Warranty Ease Battery Chg. On-going expense

Factor in yellow denotes top ten correlate of overall satisfaction.

Consumer Need for a Volume Control

Yes 28% Yes 35%

No 46% Not sure 26%

No 40% Not sure 25%

Single Microphone

Multiple Microphone

Customer Satisfaction is related to Need for a VC

% Overall satisfaction 100 80 57 60 42 40 20 0 Single Multiple Number of Microphones 60
Desire for Volume Control? Yes Not sure No

93 79

81

Significant Differences

Performance Factors
Single Mic & MarkeTrak

Factor

Multiple Mic & MarkeTrak

Multiple mic & Single Mic

Benefit Reliability Sound clarity Natural sounding Sound of voice Soft sounds Loud sounds Whistling/feedback

Factor in yellow denotes top ten correlate of overall satisfaction.

Performance Factors (Cont.)

Factor
Single Mic & MarkeTrak Multiple Mic & MarkeTrak Multiple mic & Single Mic

Significant Differences

Value (price/perf.) Directionality Use in Noisy Sit. Battery Life

Factor in yellow denotes top ten correlate of overall satisfaction.

Significant Differences

Listening Situations
Single Mic & MarkeTrak

Factor

Multiple Mic & MarkeTrak

Multiple mic & Single Mic

One-on-one T.V. Small Groups Listening to music Place of worship Outdoors Leisure activities

Factor in yellow denotes top ten correlate of overall satisfaction.

Listening Situations (Cont.)

Factor
Single Mic & MarkeTrak Multiple Mic & MarkeTrak Multiple mic & Single Mic

Significant Differences

Car Restaurant Concert/movie Workplace Telephone Large group

Factor in yellow denotes top ten correlate of overall satisfaction.

Summary of Key Findings

Single Mic DSP
Overall customer satisfaction improvement (vs. MarkeTrak)
Factors with 10%+ improvement (vs. MarkeTrak)

Multiple Mic DSP

+17%
14

+3%
4

Top ten consumer factors improved (vs. MarkeTrak)

Net listening situations improved (vs. MarkeTrak) Net performance/value factors improved (vs. MarkeTrak) Significant differences (single vs. multiple microphone DSP)

0
-1 -2 1

6
4 6 14

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).

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.

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).

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.)

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.

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

MicroWaxbuster Cutaway

CIC with MicroWaxbuster installed

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.
100 90 80 70 60 50 40 30 20 10 0
Receiver Replacement Index

100 88 66 60 48

18

13

None

1-9%

10-19% 20-29% 30-49% 50-69%

70%+

Waxbuster/MicroWaxbuster Usage

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.

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

45
Receiver Replacement Rate
MicroWaxbuster No Wax Guard Poly. (No Wax Guard) Poly. (MicroWaxbuster)

40 35 30 25 20 15 10 5 0

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Age of Hearing Aid (Months)

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

30
Receiver Replacement Rates
MicroWaxbuster No Wax Guard Poly. (No Wax Guard) Poly. (MicroWaxbuster)

25 20 15 10 5 0

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Age of Hearing Aid (Months)

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

30

MicroWaxbuster
25
Receiver Replacement Rates

No Wax Guard Poly. (MicroWaxbuster) Poly. (No Wax Guard)

20

15

10

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Age of Hearing Aid

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.

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

Soft Shell Technology

Improved
Improved Other

fit & comfort

fit with torturous ear canals

potential benefits:

> gain before feedback < displacement of hearing aid

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 hearing aids (3-D digital models of the ear canal)

Impressionless

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 Potential importance for third party payment Improving physician referrals Shaping consumer expectations Trouble shoot unsuccessful fittings

Document reduction in disability

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?

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

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)

MarkeTrak Norms: Select Customer Satisfaction Factors

MarkeTrak Norms: Customer Satisfaction in Select Listening Situations

Percent of Consumers Receiving Follow-up Customer Satisfaction Survey

(H.I. < 6 years compared to H.I. <1 year in age).

Post-survey method None Verbal office Mail Written office Phone Computer office 0 9 8.7 5.3 7.1 4.1 2.6 1.7 3 5 Age of H.I. H.I.< 6 years H.I.< 1 year 10 15 20 25 30 35 40 45 50 55 60 65 70 Percent hearing instrument owners 21.1 21.5 58.9 57.2

Overall Satisfaction Improves with Post-fitting Survey Follow-up

(H.I. < 6 years compared to HI < 2 years).
Post-survey method None Verbal office Mail Written office Phone Computer office 30 40 50 60 62 61 70 80 64 69 54 57 62 60 68 71 69 72

Age of H.I. < 6 years < 2 years

Percent overall customer satisfaction

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

Some Final Considerations

Measuring

performance helps drive

success.
Without

effective measurement how can we assure we have optimized the customers hearing experience?

Without

effective measurement how can dispensers grow in their wisdom on behalf of the consumer?

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

U.S. Binaural Hearing Instrument Owner Population Trend

80 70 Total Owners 65 Total Owners - Current year 60 51 50 40 30 22 20 10 0 1984 1989 1991 1994 1997 2000 2004 25 37 47 52 61 60 65 64 74 70 74

% of Hearing Instrument Owners

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

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

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.

scores on key factors.

Difference

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

Monaural vs. Binaural Customer Satisfaction (Key factors impacted)

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%

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):

www.betterhearing.org (market research section).

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.

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.

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.

Customer Requirements 5 dimensions

Empathy

- the degree of caring and individual attention you show to your customers. - the physical facilities and equipment and your appearance.

Tangibles

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.

An excellent starting point for your whole staff.

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

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

35 30 25 20

Percent of users

Modal time is half hour

H. I. User New < 6 years Experienced < 6 years All <1 year

25.1 24.3 25.2

15 10 5 0

31.7 31.4 29.2

13 14.4 12.8

18.3 19.8 20.7 4.4 4.6 5.7

3.3 2.2 2.2

None

0.25

0.5

0.75

Counseling time spent (hours) with users

4.3 3.4 4.3

3+

Customer Satisfaction Ratings are Related to Time Spent in Counseling

(H.I. < 6 years compared to H.I. < 1 year).

80 70 60

H. I. User New < 6 years Experienced < 6 years All <1 year

Percent of users

50 40

60 68 65

65 68 67
2

39 45 42

20 10 0

None

42

0.25

52 48

0.5

0.75

53

30

54 63 59

3+

Counseling time spent (hours)

65 59

59 64 62

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

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

www.knowleselectronics.com

Recommended Readings: J. Abrahamson - post fitting group sessions. C. Palmer & E. Mormer - Systematic counseling protocol C. Edwards - pediatric population

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.

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

Attitude
Trust in doctors Trust in audiologists Trust in HA dealers HA sellers customer oriented HA sellers take advantage Exposure to TV ads Truth in advertising 30 day trial knowledge
Attitude Neutral 7.5 10.6 12.2 12.1 39.7 37.9 37.6 17.7 30.3 80.3 38.3 51.5 53.4 49.1 48.3 71.6 58.5 11.1 12.2 49.6 36.4 7 13.1 14.2

0%
Positiv e

20%

40%

60%

80%

100%

Negativ e

Percent

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

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

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.

Comprehensive Fitting Protocols

Models

of hearing aid success needed:

Matching technology with consumer hearing loss characteristics at the point of sale.

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

Washington University School of Medicine

Sample Protocol

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.

Washington University School of Medicine

Sample Protocol

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

Washington University School of Medicine

Sample Protocol

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*

* Currently under consideration

Washington University School of Medicine

Sample Protocol

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.

* Currently under consideration

Washington University School of Medicine

Sample Protocol

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.

Best Practices Discussion Items

Benefit is Critical to Market Growth

High

benefit is related to: High customer satisfaction High brand retention customer satisfaction : Leads to positive-word-of-mouth advertising And therefore market growth

High

Benefit is Critical to Market Growth

Important

to focus on the dispensers role in optimizing consumer benefit. consumer benefit is 44% HL problem resolution in U.S. How can we improve to 65% benefit in 5 years?

Current

Selection/verification/validation Some Considerations

Convene committee of industrys 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)

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)

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 enduser.

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

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

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 dispensers office with hearing aids that are too loud?

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.

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.

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 consumers hearing loss characteristics?
consumers be made to pay for hearing instruments with little or no measurable benefit? (e.g. speech intelligibility improvement).

Should

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 Dispenser energy expenditure (time, service, product).

Consumer

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

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.
hearing aid dispensing outlets earn such a best practices seal of approval through an independent audit?

Should

Similar to ISO 9002 quality certification

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

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.

Value

Dispenser Consumer

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.

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

What is Value?
Service

provided + performance of hearing instrument (benefit) to how much was paid for the product & service

Relative

What is value?
Price of hearing Price of hearing aids/service aids/service --------------------------------------------------------Benefit = need fulfillment Benefit = need fulfillment

Value = Value =

Benefit APHAB= Unaided -- aided Benefit APHAB= Unaided aided ------------------------------------------Unaided Unaided = % reduction in disability. = % reduction in disability. =$$ paid per % disability reduction. =$$ paid per % disability reduction.

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

100 95 90 85 80 75 70 65 60 55 50 45 40 35 30 25
5 15 25 35 45 55 65 75 85 95 125 200 500

Overall Benefit Value Poly. (Overall) Poly. (Benefit) Poly. (Value)

Satisfaction

Price ($$) spent per 1% disability improvement

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

Overall Customer Satisfaction (%)

Price Hearing disability improvement (%)

R2=.86

Hypothetical Situations - Value

Handicap Reduction

Price

Value

Comments

-25

1000

-40

Consumer's hearing got worse & lost money

10

500

50

Low benefit at low price

100

5000

50

Great benefit at a high price

Satisfaction is Related to the Age of the Hearing Instrument

70 60

Satisfaction

50 40 30 20 10 0 <1 1 2-5 6-9 10-14 15+ Age of Instruments

and to Hearing Aids in the Drawer

35 30

% in drawer

25 20 15 10 5 0 1 2 3 4 5 6 7 8 9 1014 15+

Age of Hearing Instruments

Recommendations

Maintain contact with past consumers. Develop marketing and incentive programs to assure that technology in consumers ears is < 5 years old. Friends of consumers will judge newer technology based on consumers perceptions of 10 year old technology. Critical to work with consumers to keep hearing instruments out of the drawer.

A Word About Expectations

Expectations

are critical when you serve customers. them to satisfy the customer.

Meet

Exceed

then to make the customer love you.

A Word About Expectations

Set

unrealistic expectations--in essence, you can never hope to keep--

promises

then:
your

customers will hold you beneath contempt.

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) www.knowleselectronics.com Rose Allen www.audiologyonline.com 5/20/02

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

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.

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)

Our Role is To Assure the Customers 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