In a recent interview, Richard Branson, who is chief executive officer of the Virgin Group, explained how he dealt with the following business conundrum: “Who comes first, your employees, your shareholders, or your customers?” He said, “…My philosophy has always been if you can put staff first, your customer second, and shareholders third, effectively, in the end, the shareholders do well, the customers do better, and yourself [sic] are happy.”
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Branson’s employee-first philosophy has been successful for the Virgin Group. The Virgin-branded businesses span the following multiple sectors: travel and leisure, health and wellness, music and entertainment, telecoms and media, financial services, and space. Virgin Mobile has consistently been recognized for being at the top of the industry for wireless customer care satisfaction.- Schurenberg E.
Richard Branson: Why customers come second at Virgin. In an exclusive Inc. interview, Sir Richard explains who rates highest at Virgin. And it’s not investors, either. Inc. com.
https://www.inc.com/eric-schurenberg/sir-richard-branson-put-your-staff-first-customers-second-and-shareholders-third.html
Date accessed: February 8, 2023
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- Malik A.
Virgin Mobile ranks first for wireless customer care satisfaction: study. Mobile Syrup.
https://mobilesyrup.com/2020/05/06/virgin-mobile-wireless-customer-care-satisfaction-study/
Date accessed: February 8, 2023
Such evidence from industries outside of health care suggests that employee satisfaction correlates with customer satisfaction, with attendant benefits to the companies involved. Analysts at Glassdoor, which is a worldwide leader on insights about jobs and companies, sought to answer the question, “Can companies help to achieve high customer satisfaction by investing in employees and ensuring that those who deliver goods and services are themselves satisfied with their jobs?”
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To find the answer, the analysts considered reviews from Glassdoor employees and ratings from the American Customer Satisfaction Index. The American Customer Satisfaction Index is a national cross-industry measure of how satisfied customers are with the quality of products and services (300,000 US customers rating 293 large employers from 13 industries). For each 1-star improvement in a company’s Glassdoor rating, the customer satisfaction score increased by 1.3 points of a possible 100 in the survey, which was a statistically significant improvement and over twice that of industries where employees did not have frequent and friendly interactions with their customers. Although observational, the study results suggest that employee satisfaction is directly associated with customer satisfaction. These results in turn prompted our following question: Has the time come for greater intentional focus on health care employee satisfaction as a means of improving patient satisfaction with the care that they receive?- Chamberlain A.
- Zhao D.
The key to happy customers? Happy employees. Harvard Business Review.
https://hbr.org/2019/08/the-key-to-happy-customers-happy-employees
Date accessed: January 25, 2022
In a survey of medical students from the American Medical Association, 75% of respondents reported their primary motivation for a career in medicine was helping people.
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This motivation is consistent with the following Triple Aim described by the Institute for Healthcare Improvement as an approach to optimize health care performance: improving the patient experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of health care.5
In an ideal state, health care employees and patients join together in a mutually beneficial relationship without hierarchy. They engage in a harmonious relationship built on values of mutual respect, with goals focused on optimizing patient care and outcomes consistent with the Triple Aim.The IHI triple aim. Institute for Healthcare Improvement.
http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx
Date accessed: January 25, 2022
The Triple Aim, as described by Spinelli,
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has unfortunately resulted in what the author termed “phantom limb pain” or a focus on the quality of patient care, the total cost of care, and the patient experience of care at the neglect of the phantom limb, which is the well-being of the health care workforce. Burnout and general job dissatisfaction among health care professionals manifest this phantom limb pain. In 2014, Bodenheimer and Sinsky7
introduced the idea of expanding the Triple Aim to a Quadruple Aim, which added the goal of “improving the work life of health care professionals, including clinicians [and other members of the health care] staff” as a critical component of improving patient experience and health outcomes. Notably, physician-specific factors have been reported to significantly influence patients’ satisfaction with their experiences and their likelihood of recommending the practice. In the past 5 years or so, increased attention has focused on physician burnout and its consequences,3
,- Chamberlain A.
- Zhao D.
The key to happy customers? Happy employees. Harvard Business Review.
https://hbr.org/2019/08/the-key-to-happy-customers-happy-employees
Date accessed: January 25, 2022
8
but the importance of the well-being of the entire health-care team cannot be overstated.- James T.A.
Engaging physicians to lead change in health care. Harvard Medical School.
https://postgraduateeducation.hms.harvard.edu/trends-medicine/engaging-physicians-lead-change-health-care
Date accessed: October 11, 2022
9
Acknowledging the significance of the collective care team does not diminish the role of physicians who serve as a motivating force for quality improvement initiatives and for inspiring colleagues. Physician engagement may be necessary to provide the fundamental insight and leadership essential for successful transformation of health care.The Quadruple Aim enhances the Triple Aim by addressing the “phantom limb pain” described by Spinelli,
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which is complex and chronic for burned out and overwhelmed health care professionals. Although the importance of clinician well-being and burnout affecting health care professionals is increasingly recognized, progressive changes are needed to address those goals.Enhancing the patient experience is a universally understood objective in health care organizations. An engaged and empowered workforce is therefore critical to improving patient experiences. The focus should be on physicians and the collaborative care teams. Staff need to have a sense of meaning, purpose, choice, autonomy, and psychological safety if they are to perform their best. The burden of electronic health records and other avoidable, time-consuming issues must be lessened. Leaders in wellness-centered leadership must also be trained to inspire and motivate the health care workforce.
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Evidence suggests a positive relationship between practitioner and patient satisfaction. Still, more research is needed to clarify the effects of one on the other.
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Such studies would be particularly timely because physician compensation is increasingly tied to patient satisfaction metrics.- Hodkinson A.
- Zhou A.
- Johnson J.
- et al.
Associations of physician burnout with career engagement and quality of patient care: systematic review and meta-analysis.
BMJ. 2022; 378e070442https://doi.org/10.1136/bmj-2022-070442
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Therefore, the time is ripe for pursuing the fourth element of the Quadruple Aim—which is clinician well-being. Understanding progress toward that goal is critically important.- Japsen B.
Physicians See More Pay Tied To Patient Satisfaction And Outcomes. Forbes.
https://www.forbes.com/sites/brucejapsen/2019/07/08/physicians-see-more-pay-tied-to-patient-satisfaction-and-outcomes/
Date accessed: January 25, 2022
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Meeting the needs of their patients is an essential motivator for health care professionals, which aligns with survey findings of why medical students choose medicine as a career. However, it is time to consider that health care should mirror other industries and elevate the importance of satisfaction of health care professionals, which could improve experiences and satisfaction for both groups, as was shown by the Glassdoor survey. Failure to address the fourth aim of the Quadruple Aim, which is managing and improving the work life of health care professionals, will cause more burnout, dissatisfaction, and chronic anguish. Focusing solely on patient satisfaction in isolation may paradoxically result in decreased patient satisfaction and worsening patient outcomes.
If I had the opportunity to sit down with Mr. Branson and solicit his opinion on the relationship between physician satisfaction and patient satisfaction, he would likely believe in a positive correlation between the 2 groups. However, without more evidence of a correlation, meaningful cultural changes that would place physician satisfaction on an equal plane with patient satisfaction are unlikely to occur in the health care sector, as are substantial interventions to improve the satisfaction of overburdened physicians.
Potential Competing Interests
The authors report no competing interests. Mayo Clinic does not endorse specific products or services in this article.
Acknowledgments
Marianne Mallia, ELS, MWC, senior scientific/medical editor, Mayo Clinic, substantively edited the manuscript. The Scientific Publications staff at Mayo Clinic provided proofreading, administrative, and clerical support.
References
- Richard Branson: Why customers come second at Virgin. In an exclusive Inc. interview, Sir Richard explains who rates highest at Virgin. And it’s not investors, either. Inc. com.https://www.inc.com/eric-schurenberg/sir-richard-branson-put-your-staff-first-customers-second-and-shareholders-third.htmlDate accessed: February 8, 2023
- Virgin Mobile ranks first for wireless customer care satisfaction: study. Mobile Syrup.https://mobilesyrup.com/2020/05/06/virgin-mobile-wireless-customer-care-satisfaction-study/Date accessed: February 8, 2023
- The key to happy customers? Happy employees. Harvard Business Review.https://hbr.org/2019/08/the-key-to-happy-customers-happy-employeesDate accessed: January 25, 2022
- Survey shows why doctors choose medicine and the challenges they face. The Washington Post.
- The IHI triple aim. Institute for Healthcare Improvement.http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspxDate accessed: January 25, 2022
- The phantom limb of the triple aim.Mayo Clin Proc. 2013; 88: 1356-1357https://doi.org/10.1016/j.mayocp.2013.08.017
- From triple to quadruple aim: care of the patient requires care of the provider.Ann Fam Med. 2014; 12: 573-576https://doi.org/10.1370/afm.1713
- Engaging physicians to lead change in health care. Harvard Medical School.https://postgraduateeducation.hms.harvard.edu/trends-medicine/engaging-physicians-lead-change-health-careDate accessed: October 11, 2022
- Charter on physician well-being.JAMA. 2018; 319: 1541-1542https://doi.org/10.1001/jama.2018.1331
- Wellness-centered leadership: equipping health care leaders to cultivate physician well-being and professional fulfillment.Acad Med. 2021; 96: 641-651https://doi.org/10.1097/ACM.0000000000003907
- Associations of physician burnout with career engagement and quality of patient care: systematic review and meta-analysis.BMJ. 2022; 378e070442https://doi.org/10.1136/bmj-2022-070442
- Physicians See More Pay Tied To Patient Satisfaction And Outcomes. Forbes.https://www.forbes.com/sites/brucejapsen/2019/07/08/physicians-see-more-pay-tied-to-patient-satisfaction-and-outcomes/Date accessed: January 25, 2022
- How to measure progress in addressing physician well-being: beyond burnout.JAMA. 2021; 326: 2129-2130https://doi.org/10.1001/jama.2021.20175
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Published online: March 17, 2023
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