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VOC Toolkit

Designing for the Voice of the Customer In a Healthcare Setting. 1

“Getting beyond better sameness involves engaging customers in fundamentally different kinds of conversations and getting beneath the surface of what they say to understand their deeper goals and the experiences they’re having.” - Frank Capek Customer Innovation Inc.


Contents Defining the Voice of the Customer History and Background

4 6

Examples of Success in Healthcare


Tools Used to Achieve Voice of the Customer


VOC Used at Cardinal Glennon


Quality Function Deployment Sales Technology Design Architecture Healthcare

IDEO’s Focus Design for Texas Children’s Pediatric Associates SSM St. Clare’s Patient-Experience Based Design St. John’s Mercy Patient-Centric Focus

Dashboard Software User Groups Electronic Surveys Qualitative Spatializations Vision Boards Blink Test Design Criteria Check In Interviews of Key Leadership Post-Occupancy Test and Survey Hypothetical Narratives Space Observation Mock-Ups Patient Experience Planning Groups “Is”-State Mapping Town Hall Check In Accessing Client Data Findings and Results

Design Process to Tap into VOC References

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Defining the Voice of the Customer Voice of the Customer (VOC) is a term used in business and information technologies to describe the in-depth process of capturing a customer’s expectations, preferences and aversions. It is a market research technique that produces a detailed set of customer wants and needs, often prioritized in terms of importance. It can be both qualitative and quantitative. It has a wide variety of uses, but this report will focus on its application to the world of architecture and specifically, healthcare-related architecture. The term VOC originated in the sales sector, making its way into the technology, design and architecture profession. Most recently, the healthcare industry has been particularly interested in the term and has worked to apply the Voice of the Customer to everything from complete patient experience to individual wall color. Many additional terms exist for the Voice of the Customer that have similar, but slightly different meanings such as: • “User-Driven Design”: Based less on the customer, and more on the main user of the product of space. • “User Experience Design (UXD)”: While the word “experience” doesn’t begin with an “X” the term focuses on creating a customer experience through written narrative and day-in-the-life play by plays. • “Market Research Application”: Less concerned about the individual customer experience, and more about exploiting the market • “Quality Function Deployment”: More focusing on the engineering and production of a product based on the user, than on the customer experience. • “Design for Six Sigma”: Applies VOC but also very focused on the profitability of any changes made. Very systematic and corporate system. For most companies, the customer is the body of people who directly purchase the products they produce. Doing research on what their consumers want and need in a

Vs 4

Most smart phones improve with “better sameness” but never truly innovate. The iPhone 4 took user input to redefine a phone call.

product allows them to create a better service/product/experience, which then is ideally well received by the customer. For Christner Inc, the customer would fiscally be the client who hires the firm to design and plan their next construction. There currently is a rich toolbox used to extract the requirements, visions, and goals for the project from the client. However, designing for the Customer of the Client adds an additional perspective and new source of input. Many companies have found this strategy to open the door to new innovation, allowing for both the client and the customer to benefit as a result. There are many positive, and marketable assets to discovering and designing for the Voice of the Customer. The most tangible being: • Addressing and understanding the needs of the customer that may not be expressed by the client. • Allow for innovation in design by addressing the core concerns and desires of the customers, both spoken and unspoken. • Help create emotional/signature experiences • Create a brand and competitive differentiation of your product and design. • Create ownership with customers of the company’s products by giving them a say in design (A marketing tool) • Distinguish services from competitors through user-based innovation. • End with a product that is more efficient and functional There are countless ways to tap into the Voice of the Customer from surveys, interviews, observations, vision boards, and more, all of which will be discussed more at length later on. While some are more successful than others, each provide a helpful insight into the mind and emotions of the customer, which can be applied to design. Designing with the Voice of the Customer in mind can be a powerful tool that could radically innovate design. One of the main attributes of VOC is to design with just the ideas of the customer in mind, ignoring the expected or typical solution to problems. This process allows for a completely innovative and creative solution to a problem. The following pages will provide examples of how VOC has been used in design to innovate throughout history, along with tools to innovate in the future. 5

History and Background The Voice of the Customer has been used by many different industries to achieve better products and services. Below is an explanation of the origin of the term and how is has been used in different ways in the last thirty years. On the adjacent page, you can see the time line that highlights the use of the phrase in different industries during the past 50 years.

Quality Function Deployment The predecessor to VOC is often considered to be “Quality Function Deployment”. This term came about in 1966 in Japan by Dr. Yoji Akao, a planning specialist who created a technique to integrate customer requirements into product design. QFD uses quantitative measurements and is often applied largely to engineering and product design. It is often considered one of the first formalized systems for integrating customer and user requests into design, which is the reason for its connection to Voice of the Customer. The figure to the right is an example of a product development map known as the “House of Quality”. This tool, used in QFD, compares the needs of the customer to the capabilities and goals of the company. It provides a numeric and tangible way of looking at the rewards of an additional service, function or design for your product. The desires of the customer are also weighted to provide information regarding what is most important to the customer, as fewer innovations in the correct areas can be much more financially viable than guessing what the customer wants the most. [7]

Sales The birth of the phrase “Voice of the Customer” began in corporate culture and sales in the 1980’s. It took many of the same principles of QFD and used them 6

House of Quality tool for evaluating corresponding solutions and customer values. [7], [14]

for to create customer experiences and for marketing. VOC was used in the service industry in the 1980’s in addition to product engineering and design. Many companies started to value their marketing staff as “customer feedback” monitors, taking their input and applying it to design. If the marketing staff knew what customers wanted, they could take that info, apply it to their product or service, and go out and sell it. Most of the techniques to reach the VOC were largely comment card, survey and customer-service based. There was little done to go deeper into the thought process or psychology of customer choices. This is called “reactionary” feedback. Additionally, most changes from customer input were relatively timid, making things better in a lot of cases, but not necessarily innovating and revolutionizing; what is called “Better Sameness”. One of the best examples of this is the design and development of the 1986 Ford Taurus. The designers set out to react to the Voice of the Customer and integrate feedback into design. The interior was designed to be extremely user friendly, with all of its controls designed to be recognizable by touch (a feature first suggested by the customer in a focus group). The interior was highly customizable to fit buyers’ needs, with a large number of options and three different configurations. This type of customization was not available up until now in the same model. This allows the customer to get the exact amenities they desire in a car which creates better sales and happier customers. The Taurus was very well received by the press and the public due to its innovative design that was spurred by the input from Timeline of VOC customers in surveys and focus groups. “Let’s get rid of ‘opinioneering’ and start building cars that meet the voice of the customer!” - Neil Eldin and Verda Hikle, 1987. The 1986 Ford Taurus won Car and Driver’s car of the year for its inventive, user-driven, design


Technology In the 1980’s and 1990’s, the boom in technology and the personal computer opened the doors to a whole new realm of Voice of the Customer design opportunities. During the 1970’s, and early 1980’s, the user-interface for computers was designed by a few software engineers on the west-coast. Their creativity, which typically computer engineers are not known for, was the limit for innovation in early PC systems. Later, when the industry began looking to the Voice of the Customer, the way people interacted with technology was studied, which influenced future design.

The move from MS-DOS to the first mouse illustrates the application of VOC to UI design.

The advent of the internet provided a whole new means of connecting with customers to get user-feedback and input. Surveys could be done on an international basis. As a result customer tracking on websites has become more and more prevalent. The vast body of internet-user information has been harnessed and used for website and product design. A more recent example of the use of user-driven design is a group of UC Berkeley doctors and computer engineers who designed a computer game for children that would screen for a genetic disease called Fragile X syndrome. The game monitored their reaction time and their ability to follow characters and commands. They would bring the computer to an Oakland classroom to test on their users (children and the teachers operating the device) and would take notes on their operation of the software. They would then return to the drawing board and redesign the software, retesting it the following week. This continued until the end product was successful in its mission and fun to use. [4]


The participatory design or co-design process with the customer allowed for a userinterface and final product that was most successful at identifying Fragile X and was fun for the children

Design When VOC reached the design sector, it was largely focused on creating a unique customer experience. Designers were no longer interested in “better sameness�, improving a product slightly, but not significantly enough to call it innovation. By completely rethinking a product or system to create an experience, a brand is created and the product’s value is significantly greater. This is largely the thinking of the design firm IDEO, which has been hired to completely retool customer experience and product design for many major companies. Design innovation such as this started to go beyond the typical survey or comment card (Reactionary) VOC process, and moved to additional observation, psychological studies and interviews (Proactive) to apply VOC to the design. Additionally, the idea of prioritizing needs of customers led to efficient innovation while designing to include the Voice of the Customer. Often the laundry-list of wants and needs can be thoughtfully reduced to key changes that will most-significantly influence use of the product. If a new pacemaker is requested and then you have your customer rank, prioritize and dollarize the 24 or so features of the pacemaker, you will find that they would quickly realize that they only really need 10% of the features that they thought they originally required. This can reduce the cost of new innovative pacemaker design by 23% or more based on studies by members of the field.

Architecture Architectural design influenced by Voice of the Customer stems from the PostModern belief that architecture was not a personal philosophical or aesthetic pursuit by individualists; rather a consideration of the everyday needs of people and use of technology can create a livable environment. There has been an increased interest in designing space based on the VOC. This will not only increase user satisfaction, but boost customer visits and profits. This is a very marketable feature of a design process, in that it has the potential to truly strengthen customer loyalty. Bruce Temkin, founder of the Temkin Group, is a significant customer experience expert who talks about the architecture of a whole company and a designing of its customer experience. Sometimes, a company cannot afford to change the quality or efficiency of its service, but it can improve the time people wait and the customer experience.

One example that Temkin cites involves commercial real estate managers responsible 9

Influence Perceptions

Improve the Realities

$10 Million Upgrading

for several high-rise office buildings in New York. Managers were trying to figure out how to address customers’ dissatisfaction with the amount of time spent waiting for elevators during peak periods.

Not surprisingly, if you ask customers what they want, the elevators they’ll tell you that they want an increase in service levels: faster elevators and less waiting. Obviously, the complexity and cost of actually improving service levels are quite high; It would involve installing faster elevators, dedicating more interior space to elevator banks, improving the optimization of elevator queuing, etc. $10,000 Installing mirrors in the lobby

It turned out that the most effective improvement was to install mirrors in the elevator lobbies. This allowed people to entertain themselves by fixing their hair, straightening their tie, and checking each other out in a much more socially acceptable way. The perceived experience improvement was greater with the relatively low cost mirrors than with the relatively high cost technology required to improve actual service levels. [17]

Healthcare Most recently, the Healthcare industry has seen growth in redesigning their patient experience by taking into account the VOC. This industry, more than most, has customers who demand and expect a good customer experience, for both inpatients and outpatients. As a way to distinguish a health system, clinic or hospital, user-driven design of space and operations opens the door to innovation for this sector. The healthcare industry has three levels of “customers”:

1. Primary: Patients, Families of Patients.

2. Secondary: Doctors, Nurses, Employees. (Anyone you need to pay to train) 3. Tertiary: Referring physicians, thirdparty payers, communities. (Any additional source of primary customers) Taking all three of these levels into account when designing and managing not only retrains


Designing the patient experience from entry to discharge based on patient and staff input can revolutionize design

customers and strengthens current customer satisfaction, it can increase customer referrals, encourages staff retention, improve efficiency, and safety. Lynn Britton, Mercy Health System’s President and CEO is emphasizing Voice of the Customer in the design of Healthcare systems. He realizes that often patients visit a hospital not because of the quality of care, but because of referrals from other customers, other doctors, and from past experiences. By heeding the voice of the customer, experiences become better and business should follow suit In 2008 Mercy Health Systems introduced its VOC Planning which included the following steps:

- Facilitated market research/focus group sessions and one-on-one interviews for field research in various markets in the health system.

- Gathered hospital market intelligence data for annual Strategic Update Book; data used by key stakeholders in each hospital

- Analyzed and summarized monthly ePanel “Voice of the Customer” survey results from 300+ participants throughout five state health system region. Results posted on website for ePanel members to view and then take the next ePanel survey.

- Managed and reported system-wide Press Ganey data tracking, a healthcare survey system that reports on patient satisfaction, as well as reporting weekly progress of 10 key hospitals for inpatient, ambulatory, surgery, and emergency departments.

- Generated weekly report utilized by Senior Leadership/Board of Directors and hospital CEOs.

- Managed external strategic planning/research vendor relationships.

More and more healthcare companies are investing similarly in services like Press Ganey and introducing patient satisfaction methods. Primary customers are highly valued, so this data can be used to focus decisions, both in operations and physical design. [1] [5] [10] [20]


Examples of Success in Healthcare The Voice of the Customer has been implemented in many different ways in design. Below are a selection of examples, many from the Healthcare sector, that will illustrate some challenges, and successes they experienced.

IDEO’s Focus Design for Texas Children’s Pediatric Associates (TCPA) TCPA believed an outside perspective would catalyze its imperative for change—and it asked IDEO to provide one. The joint creative team spoke directly with families, physicians, and staff to identify and understand their needs. Their input suggested that a nextgeneration practice would make pediatric care more convenient for parents; address the needs of maturing adolescents; and streamline complex managed-care contracts and payer negotiations. With all this and more in mind, the creative team launched a prototype. It then solicited organization-wide feedback and conducted additional research. The final strategy, “TCPA – Grow With Us,” aimed to enhance the patient experience and serve as a platform for organizational change. TCPA and IDEO also reconfigured the organization’s practice space to help create a unique TCPA experience. The design changes included an open, hospitable reception area (to replace the traditional opaque wall with a hole) that would be easy for staff to monitor; a blended Quiet and Active waiting room (instead of Sick and Well) – the latter featuring an interactive photo game and place to “plug and play”; smaller “porch” waiting areas outside exam rooms to stage patients and manage people flow; and magnetic whiteboards, and retractable exam-table stairs. In addition, private offices and workspaces were transformed into shared work areas to support team-building among staff. The strategy has created a cultural shift within the organization, from “physician-driven to patient-centered,” and encouraged additional change. “Your team got us out of the box and gave us the faith to try things we wouldn’t have done on our own,” said Ayse McCracken, the then President of TCPA. Meanwhile, Cinco Ranch was one of the only sites out of 42 in the highly competitive region to outperform projections in TCPA’s first quarter. 12

SSM St. Clare’s Patient-Experience Based Design SSM St. Clare Health Center, opened March 30, 2009 in Fenton, Mo. It is an innovative, $215 Million, 158-bed replacement hospital that is a stunning example of the use of Voice of the Customer and Patient Experience design. According to Don Wotjkowski, Executive Director of Design and Construction for SSM Healthcare - St. Louis, the design process from the beginning, revolved around the patient experience. So far their breakthrough design has resulted in 99th percentile Press Ganey patient comfort and satisfaction scores as well as impressive staff feedback. The VOC process was led by HGA architects. They called the technique the “Work Process Improvement”, which used many tools to extract the Voice of the Customer and define the patient experience, but within the confines of the available resources. The decisions went through four teams: Leadership, Experience, Transformation and Design. The process began with three phases: 1. “Is-State” Mapping - Tracking a day in the life of a patient at their current hospital from parking to departure through video, photos and observation. Determine the points of frustration, success, and areas that could be improved. The key to this was allowing people to break their perceptions of how things are supposed to work and allow them to imagine the ultimate patient hospital. 2. Technology Roadmaps - Hiring a mechanical engineer to carry out mapping out technology and the experience it entails. This consultant also created Lean Process mapping for the whole hospital, which evaluated points of wasted time, energy and material and designed a more efficient system.

SSM St. Clare’s Health Center.

3. Experience Teams - Eight experience teams were engaged to create an environment that would foster the best patient experience. Each group consisted of patients, physicians, staff and stakeholders. They were tasked with defining design goals and desires through patient narratives, skits of 13

interactions (ideal and negative). Some of the ideas they extracted included: multiple entrances determined by the service needed; clustered parking areas, grouped and comfortable waiting areas, quiet inpatient areas, in-room pharmaceutical storage, and spacious family areas. The resulting design took these and many other key design goals and applied them to design very well. Don Wotjkowski stressed the importance of documenting the Design Criteria early during Clustered parking with multiple entrances the programming phase so that during the hand was a concept that resulted from Patient off phases of design and construction, the spirit Experience Groups. and the goals of the project are carried through all the way. The architect took charge of this process and Wotjkowski has stated that he thinks this way of design should be part of every firm’s process. To go beyond just “visioning” and really tap into the heart of the customer by facilitating research and learning labs would help to more efficiently design a hospital and create a spectacular outcome. [21] [13]

St. John’s Mercy Patient-Centric Focus Since 2008, Mercy Health System has been implementing Voice of the Customer in its physical design and day-to-day operations. I met with Cindy Beckham, former Christner employee, and current Executive Director of Facility Design for Mercy about her work in the VOC field and what Mercy has been working on from a St. John’s Mercy’s new brand focuses on a branding perspective. customer-centric healthcare system in both facilities and operations. She was brought on to help make sure all Mercy facilities are designed as dictated by the Voice of the Customer, and specifically, “Patient Narratives”. Currently, there are eight facility models they use systemwide and she is working to apply VOC to the individual projects. She explained the whole brand is moving toward “Patient-Centric” Healthcare. Every space seeks to incorporate the 5 Mercy “Value Words” and history to design a space that says “Mercy”. There are five main VOC tools she uses: I. Observation of Patients: This is simply spending extensive time in healthcare spaces and observing how patients, families and doctors use the space. Observation reveals some of the subconscious thoughts that help dictate space design. Cindy found this to be a very 14

useful tool. II. Rolling Focus Groups: A rolling focus groups takes volunteers around to different hospitals in a van and asks them to comment on the spaces. It was found to be helpful, but the least powerful of the five tools. III. E-Survey: 20,000 people are registered for their monthly survey list that poles preferences on everything from furniture to paint color to space layout. IV. Focus Groups: Focus groups draw upon customers from many backgrounds and experiences. Probing questions can be asked that give powerful feedback. Verbal responses typically are more helpful than written, and in this case, many design criteria can come from a group such as this. V. Customer Advisory Group: A Customer Advisory Group is a consistent group of people who advise development plans and design throughout a building and design process. It is helpful in its returning presence that is not achieved in individual focus groups. [3] [1]


Tools Used to Achieve Voice of the Customer Below are examples from Christner of what is already done to tap into the Voice of the Customer and extract the needs, visions and goals of the client. These and others can form a “tool-kit” to gain information from the customer of the client.

Dashboard Software Client-focused Developed by Christner for use with clients, this software program can demonstrate needs and illustrate expected changes in different medical services based on myriad inputs such as current size, operating hours, staff members, projected growth rate, and more. What makes this system especially compelling to clients is the ability to illustrate change in real time. It does not require one to completely retool a presentation to a client if data is evolving, rather inputs can be adjusted mid-presentation or reflect scenarios for multiple design opportunities. The client has visual assurance that their voice is being heard. It is a quantitative way of getting input from the client regarding needs, requirements and goals for the future.

User Groups


User groups test out designed space and potential purchases before hand, imparting years of knowledge into an otherwise assuming designer

Client-focused, and Patient-focused Often compiled by the client, the user group provides insight into practical day-to-day usage of the space. CardinalGlennon Children’s Hospital compiled a user group to help the design process of their new Fetal Care Unit. It consisted of nurses from many backgrounds, one of whom was pregnant, a doctor, and facilities manager. User groups are typically most successful when they contain people of varied backgrounds. More often than not they contain just employees of the company. Ideally, the

user group would include customers too. Many of the healthcare clients we interviewed explained there are already patient focus groups in place at the hospital. The goal is to tap into that feedback directly by attending those meetings and having sustained interfaces throughout the design process. Clients and users of the space know their input was heard, and many years of experience can be passed on to the designer. Having a consistent group of users throughout the design process allows them to think through issues over the long term, rather than a few minutes with a survey or other short-term interface.

Electronic Surveys

Client-focused, potential for Customer-focus Often Christner uses electronic surveys to gather client preferences and needs by distributing them to employees, stakeholders and users of the space. The goal is to send these to customers as well. This would allow us to tap into the opinions of the customer directly to design better spaces for the customers.. The design of surveys should allow for the customer to prioritize their desires or needs. Without this mechanism, it is difficult to determine what is most important to people. Qualtrics is a company that offers online survey capabilities that allow people to respond to touch screens to voice their opinion. Heat maps of preferences can be Triangle and line Test generated, as well as text entries and sliding scales can be achieved. iPads or iPods could be used on PHYSICAL CHARACTERISTICS location to poll customers while they wait, or the same survey could be emailed to the customer.

Qualitative Spatializations

Client-focused Triangle test: a test given to stakeholders and company leadership to identify where they want to see change in the operation and organization of their company. Could this test be reworked for healthcare and given to customers? Could it identify how customers want to see their healthcare system run on an operations level? This could give the basis for a truly innovative design that touches healthcare and corporate design in a very new way. Line Test: Allows customers to place their desires on a scale and get a visual and semi-numerical analysis of the client’s desires.





















Mother of Good Counsel Home


9 January 2006


Vision Boards Client Focused

(ie. Arlington Grove Survey and Landscape board) Shown to stakeholders and community leadership to allow them to visualize the characteristics of their community. It helps them accurately place their “vision” in the context of a consistent framework. Understanding what type of an environment the customer wants could also really impact long term customer satisfaction. Are patients more inclined to visit a hospital or clinic with a more formal/informal, modern/classical design?

Blink Test

Client and Customer Focused This test flashes images of interiors, exteriors and building types and allows the user-groups to make quick decisions about their reaction to the images. A digital version of this test could be made on

Overall Impression





Design Criteria Check In


Overall Impression






Blink Test examples

Documenting all of the Voice of the Customer information and design criteria early in the design process, and any additions along the way is one of the most important tools of the process. Designs, documents and responsibilities pass through many hands during the design process and having a Design Criteria Check-In to have along the way ensures that these ideas are not lost or reduced.

Interviews of Key Leadership

Client Focused These interviews document how they view the existing condition and needs, desires and restrictions of the future. Also, understanding the goals for the company’s relationship with its customers will help influence design.

Post-Occupancy Test and Survey

Customer and Client Focused User surveys that test the actual function of the new construction and its success at incorporating the Voice of the Customer. The information gathered by these surveys is used in future design for that client.


Hypothetical Narratives

This narrative tracks the story, touchpoints and movements of “Eve”, a hypothetical patient.

Customer Focused (ie. Day-in-the-Life Narratives) Creative writing to design a hypothetical experience of the customer. It describes the physical and emotional characteristics that are desired in the new space or experience. Key “touchpoints” should be identified throughout the process of where the character interacts with a service, employee or space. These touchpoints can then be integrated into design.

A Day-in-the-life narrative can be written for each customer type. Giving the customer a voice that can be heard throughout all phases of the development reminds the team of the key design criteria and goals all the way through.

Space Observation Customer Focused Spending time at the site and observing how people use the space, physically, socially and otherwise, goes beyond what people say about their space and analyzes the subconscious use of the design. This tool can be time consuming, but also provides an insight that cannot be achieved with many other tools.

Mock-Ups Customer and Client Focused Either through models or full room mock-ups, this tool can help fine-tune design by having an opportunity to experience the space before the construction is complete. While this process can be expensive and time consuming, the detailed design that can come of it, and the assurance that it will be built well is worth the added cost.

This mapping of patient circulation in at Cardinal Glennon Engaging the customers on their reaction to modeled Childrens Medical Center drop off spaces can be helpful too to get their input, in addition to resulted from an observation study.

staff and stakeholders.


Patient Experience Planning Groups Client and Customer Focused SSM St. Clare was designed using this tool as a main core of planning process with great success. Multidisciplinary groups are defined and tasked with envisioning different patient experiences for different types of visitors (ie. ED visit, Visioning appointment, inpatient, etc). Full-day workshops and meetings can be help to go through the activities that define the patient experience. These groups map the ideal experience through skits, narratives, personal accounts, visual mappings and other tools. It helps unites many levels of healthcare to a common goal of improving patient experience.

“Is�-State Mapping Client Focused

This is the process of mapping out the current system and patient experience of the hospital through flow charts, videos, narratives, etc. Establish the standard and then identify failures and challenges. This will allow the team to find the most important areas to focus to their efforts. A key to this process is to not fear change in the standard process to develop the optimal system and patient experience. Allows people to truly see the system as it stands and redevelop from that. This also is an opportunity for stakeholders and corporate leaders to see firsthand the patient experience.

Town Hall Check In

Customer Focused Establishing meetings early in the design process to touch back with stakeholders, users, customers and community leaders on the progress of the design process is important to get feedback and ideas mid-way through the process. These gatherings can also help garner support for a plan, as everyone is able to voice their concern and questions. Using these meetings as an opportunity to check in with design criteria is important.

Accessing Client Data

Client Focused One simple yet important tool is to request information that the client has already compiled regarding the voice of the customer or operations. We often find that clients already have compiled lots of research regarding their customers and simply do not think to share it. Patient survey data, comment card feedback, operations schedules, and stories are all important and can help stimulate design.


VOC Used at Cardinal Glennon When designing the new waiting areas for Same Day Surgery, Christner sought to try out some of its “Voice of the Customer” tools to develop a more powerful and satisfying space for families waiting for their children while in surgery. The tools we used for this relatively small project were few, but still gave us some very tangible design criteria to develop the space with. The current surgery waiting area at Cardinal Glennon was divided between three spaces on the sameSurgery floor, but divided by the elevators as such: Waiting Observation, Interview, and Survey results Hallway Seating (10 Seats) Small Surgery Waiting (12 Seats)

Sister Noreen’s Room (19 Seats)

Our designSeating: requirements were to expand the Small Surgery Waiting area (in green) Hallway into the adjacent abandoned staff locker room to create a new fifty-seat waiting area to • Average wait time: 1.1 Hours eliminate need forparty hallway • the Average size: 2seating. People Determining a system for recepection and consult were also of the project. • partChildren in party about 40% of time, mostly infants, and some 5-8 range.

Average grade given to waiting area: B-

The toolswould usedmove included: • VOC People to the hallway, even if there was space in the waiting area, especially

if they had children 1. Family Surveys. - Using paper surveys, I polled the families waiting in all three conditions over the course of two days. Questions were designed to give us a sense of Surgery Waiting: waiting Small context, typical length of stay, current perception of the waiting areas, preferences • Average 1.4 Hours for amenities, comfortwait in time: receiving information at different locations, and other opinions on • Average party size: 1.5 People the waiting experience. • Children in party about 10% of time, all under 3. • survey Average given to waiting area: B The led grade to some very helpful nuggets of information that we included in our design criteria. Some were to be expected but there were others that were more surprising Sister Noreen’s Room: and helpful.

Average wait time: 3 Hours

• •

Children in party about 25% of time, typically teenaged, or baby. Average grade given to waiting area: B

In• future surveying, I would do a few things differently. First, the paper survey was Average party size: 3.4 People 21

resisted by some, and people often got bored or tired. I think that a more dynamic electronic survey, such a service provided by, may led to more accurate, visual and faster results. Secondly, rather than have people rate the importance of each amenity 1-5, I would have people order the amenities from most important to least. This way you would avoid unhelpful data Below are three pages of the fivepage survey distributed to the families waiting for surgery at Cardinal Glennon.

Please help us design the optimal waiting area for the Cardinal Glennon Children’s Medical Center with your comments. Your three-pages of feedback will be used to drive our future design. 1. How long do you anticipate spending in the waiting area? 2. How many people did you bring along with you in the waiting area?

The first questions were designed too help understand context and typical wait experience in the different areas. Helped give a background of families visiting. Next we sought to understand what the current perception of quality is.

3. How many children did you bring with you today, and what are their ages? 4. How many additional people were in the waiting room while you were there?

These were designed to understand where people are comfortable receiving information, but people found it difficult to answer.

5. What grade would you give the waiting room? A











6. Please circle your answer for each of the following locations where you may have received information regarding your child’s procedure. Did you receive Info here?

Did you seek info here?

Were you comfortable with this location for info?

Reception Desk







In a private consult room







From the doctor in the waiting room







From a staff member in passing







In the patient room post-operation







7. What was most important to you when waiting in the waiting room

8. What would you have added to or changed about your waiting room experience?

On the second page we started with writein questions. People are not creative. Some great ideas came from this, but typically, response questions are better, as people could not think of things on the spot. Ranking for amenities were helpful to see what was most important. In the future, I would have them rank them in order of significance. We also had ranking for preferences on qualitative characteristics of the waiting area that led to some interesting results.


9. Please rank the importance of the following amenities in a waiting room, from 1-5. 1 being the least important, and 5 being most important. 1 2 3 4 5 Television Music Coffee/Tea Snacks/Beverages/Ice Machine Lockers for belongings Childrens’ toys and play areas Reading Material Sink Phone Internet Access (PC) Other: 10. Please rank the importance of the following characteristics of a waiting area, that you feel are most important for you. Again, 1 being least important. 1 2 3 4 5 Quiet Private space Secure Being able to sit with your whole family Playful for other children Informative of child’s procedure Other:

11. If not in the surgery waiting room, where are you most likely to be, while waiting for your child. You may select multiple answers. I do not leave the waiting area Cafeteria Outside the building Car Another waiting room In a patient room Hallway The Gift Shop Elsewhere: 12. What causes you to leave the waiting area to these, or other, locations?

The third page tried to uncover what motivated people to leave the waiting area, if at all. Turns out most people only leave for restrooms and food. If done during a programing process, this information would be more helpful. The next questions, and the questions on the subsequent pages all feature a photo of other children’s waiting areas and asked for comments on the space. Response from photos was very helpful. If people can see what they like and don’t like, they are able speak on it.

2. Family Interviews Talking with families while they waited for their child led to some important design criteria. Drawing from a wide variety of family sizes, types, What do you like most about the image above? and situations, I was able to tap into a diversity of needs that otherwise may What do you like least about the image above? not have been expressed. Many families gave me feedback on receiving consultation on the surgery in the waiting area, verses in a consult room. It helped us design our system for the receptionist to use the consult rooms with the physicians. Talking to single parents, big families, non-english-speaking parents (via interpreter), and families who had been there on multiple occasions provided a depth to design. 3. Waiting area Observation - While lockers were the lowest ranked amenity on the survey, it was evident they were a needed addition thanks to observations of the waiting experience. Families would enter with bags of belongings and clothes that they would place right next to them and fill up another seat. Other habits, such as children being taken to the hall because they were bothering others was an interesting habit that would have been lost had it not been for the observations. 4. Accessing Client Data - Christner tapped into the OR useage data of the last six months to determine the frequency of surgeries that lasted over three hours. Three hours was the length at which point people began bringing many family members and would stake out territory in the waiting areas. We thought of systems to accommodate them in new ways based on this data and developed private family waiting pods in Sister Noreen’s room. Each of the three semiprivate rooms would seat five to seven people. These rooms could be assigned to families anticipating long surgery wait time. 23

Findings and Results

After collecting the data, findings and conclusions were gathered and presented to the design team and the client. Below are pages from the findings presentation:

Surgery Waiting Observation, Interview, and Survey results Hallway Seating (10 Seats) Small Surgery Waiting (12 Seats)

Sister Noreen’s Room (19 Seats)

Hallway Seating: • • • • •

Average wait time: 1.1 Hours Average party size: 2 People Children in party about 40% of time, mostly infants, and some 5-8 range. Average grade given to waiting area: BPeople would move to the hallway, even if there was space in the waiting area, especially if they had children

Small Surgery Waiting: • • • •

Average wait time: 1.4 Hours Average party size: 1.5 People Children in party about 10% of time, all under 3. Average grade given to waiting area: B

Sister Noreen’s Room: • • • •


Average wait time: 3 Hours Average party size: 3.4 People Children in party about 25% of time, typically teenaged, or baby. Average grade given to waiting area: B

Consultation Observations: • There is little consistency in where people prefer information regarding the surgery. • Most parents want as much information as possible, no matter what the source or situation. • For good news reporting, some parents do not mind the waiting area as a location for consultation, some are uncomfortable. • Because only good news is delivered in the public waiting area, being moved to the consult room adds nervousness and fear to the process. • Perhaps if all if all conversations, good or bad, took place in the consult room, this perception could change.

Operation Length & Different Needs: • Surgeries over 3 hours results in almost twice as many family members in the waiting area as shorter surgeries. • There are typically more belongings, and a sense that families need to “stake their territory” in the waiting area. • Families with longer surgeries typically waited in Sister Noreen’s room. • There are an average of 2.7 operations per day that are 3 Hours +, and space for 3 semiprivate family pods. • Data below based on all OR use from 01/2010-06/2010.

Surgeries lasting 3 hours or more


Comments on this space: • • • • • • •

Comments on this space:

Seating looks comfortable. Looks quiet and peaceful. Colorful and Comfortable. Finishes and pattern well liked. Too confined, and dark. No television/reading material Windows good (even if to the hall)

• Ottomans and a chance to raise feet: Hugely important. • Cozy and feels like home. • Colors are warm, seats look comfortable. • Too small/cramped. • Nothing for children. • No entertainment. • Art is peaceful.

Comments on this space: • By far the most well-liked. • Open, yet grouped family seating. • Mixed reviews on the seats: Good to stretch and layout on. Somewhat cold and “uninviting”. • Desk to get information about child. • No entertainment/toys. • Stars and fish on the walls well-liked.


Amenities most-often requested: • • • • • • • • •

Outlets and more tables for laptop use Good reading material (4.0 / 5) Coffee (3.8 / 5) Water and Ice (3.9 / 5) A place to stay updated on the patient’s location/progress throughout the procedure Television (3.5 / 5) The ability to sit with their whole family in grouped seating Having both a quiet place to read/nap, and an active space to distract from the procedure. More comfortable seating (Recliners, ottomans, places to lay down)

Additional Comments: • • • • •

All the staff I talked to requested family lockers, as parents are carrying bags, and taking up seats. Interestingly, lockers were the lowest ranked amenity on the survey. People disappear from the waiting areas for a change of pace and to stretch out. If we can provide different waiting experiences within the same waiting room, keeping tabs on families may become easier. Families would like a play space for kids, but staff explain, they should not be encouraged to bring children. Accommodating kids, without encouraging them, is important. If possible, people would like something peaceful or educational on TV, such as the news. (“Planet Earth” series was suggested 3 times). The Same-day Surgery Admitting area is where all the patients are waiting with their families before surgery, but it has no toys to occupy them.

Comments on this space: • Grouped seating is great, and very spacious, but it is too open over all. There is no differentiation of space. • Kids toys are great! • Seems too narrow. • Information desk in the center would be good for patient information. • The chairs look uncomfortable. • Great windows and well-lit. • No quiet space.

Comments on this space: • Everyone loves the art on the wall. • Kids seating is very good. • Seats look uncomfortable, and the long line of chairs looks very “clinical and institutional” • No TV or reading material. • Hard floors make for a cold environment. • Good open space. • Room for wagons to get through.


The main surgery waiting area was divided up into three main areas: The Quiet Lounge area, the Television and Children’s area, and a Nourishment and Banquette area. The logic behind this design was a response to the desire for a quiet reading/napping area while at the same time having a space to be distracted from the thought of their child’s surgery and a space to work and eat. Children’s seating was provided to accommodate the other children that will inevitably be waiting with their parents. Toys were not provided to discourage parents from bringing children and for disease control and logistical reasons.

This side of the waiting area features a quiet divided space that will separate those who need a more peaceful environment.

The other side features denser seating, but still arranged in family groupings. The television and children’s seating are together to concentrate the noise.

Lockers on this side of the hallway provide families a space to securely drop off belongings before going on to Pre-Op Holding. This will save space in the waiting areas.


The Pre-Op holding area will feature added space and medical gases. The design is consistent with that in the PACU.

Banquette seating is provided with moveable tables to adjust to different family sizes. Outlets below will provide more space for laptop use.

A central reception desk will act as a greeting point and a place to receive patient information for families.

Private family pods accommodate longwait families that typically bring many more family members with them and stake out territory in open waiting areas

Comfortable furniture and separate nourishment are important for long-wait families.

Consult rooms will be across the hall from the main surgery waiting area, immediately next to the family lockers.

Consult rooms feature the same lounge furniture as in the private family pods and computer monitors for surgery imaging.

On the other side of the bank of elevators is Sister Noreen’s waiting room, which we proposed be divided into three semi-private family pods. Data from the hospital suggested and average 2.7 surgeries per day that last over three hours. Families that fall into that category can now be assigned to one of these private family pods to wait. They will also serve as consult rooms for these families with the ability to pull up medical imaging on the television. Two consult rooms for the short-wait families will be built across the hall from the main surgery waiting area. The receptionist will ideally queue up all families in the consult room for the doctor to debrief them on the surgery, regardless of good or bad news. Research suggested that when good-news consultation takes place in the waiting areas, families have an added sense of nervousness when they are sent to a consult room. By standardizing the practice of sending everyone to the consult room, some of these fears may be quelled. [10]


Design Process to Tap into VOC Below are examples of two design processes that integrate the tools and provide a rough framework for where certain tools can be implemented and when.



References 1. Beckham, Cindy. “Voice of the Customer Branding at St. Johns.” Personal interview. 27 July 2010. 2. Berwick, Donald M. “A User’sManual For The IOM’s ‘Quality Chasm’ Report.” Healthaffairs. 2002. Web. 3 Aug. 2010. <>. 3. Burchill, Gary, and Christina Hepner. Brodie. Voices into Choices: Acting on the Voice of the Customer. Madison, WI: Oriel, 2005. Print. 4. Capek, Frank. “Customer Innovations – Creating Influential Experiences.” Customer Innovations – Creating Influential Experiences. 31 Oct. 2009. Web. 04 June 2010. <http://>. 5. Carter, Ed. “BJC Facilities Use of VOC.” Personal interview. 1 July 2010. 6. Crow, Kenneth. “VOICE OF THE CUSTOMER (VOC).” New Product Development Solutions. 2002. Web. 07 June 2010. <>. 7. Ficalora, Joseph P., Lou Cohen, and Lou Cohen. Quality Function Deployment and Six Sigma: a QFD Handbook. Upper Saddle River, NJ: Prentice Hall, 2010. Print. 8. Gobeille, Alice. “Glossary.” ISixSigma. 20 Aug. 2003. Web. 03 June 2010. <http://www.>. 9. “Shift Focus - Case Studies - IDEO.” IDEO | A Design and Innovation Consulting Firm. Apr. 2009. Web. 28 June 2010. <>. 10. Hailstone, Sherlyn. “Cardinal Glennon VOC Discussion.” Personal interview. 6 July 2010. President of Cardinal Glennon. 11. HGA Architects and Engineers - Architecture, Engineering, Interior Design. Web. 30 July 2010. <>. 12. Jay, Dan. “Client and Customer Feedback at Christner.” Personal interview. 4 June 2010. 13. “Physicians Partner to Create Ideal Patient Care Unit at Future SSM St. Clare Health Center.” SSM St. Clare. 11 Mar. 2008. Web. 26 July 2010. < internet/home/SSMStClareSTL.nsf/News/1F7DA59DB36C01EF8625746500563852?opend ocument>. 14. Privett, Lance. “Blessing Hospital Voice of the Customer.” Personal interview. 22 June 2010. 15. Røtnes, Rolf, and Pia D. Staalesen, eds. “New Methods for User Driven Innovation in the Health Care Sector.” Nordic Innovation Centre (2009): 5-59. Sept. 2009. Web. 03 June 2010. < innovation_in_the_health_care_sector_final_report_web.pdf>. 16. Slack, Gordy. “Serious Play: Using Games to Screen for Fragile X.” CITRIS. 14 Jan. 2009. Web. 05 Aug. 2010. < games_screen_fragile_x>. 32

17. Temkin, Bruce. “The Current State of Customer Experience.” Customer Experience Matters. 19 June 2010. Web. 21 June 2010. <>. 18. Verderber, Stephen, and Ben J. Refuerzo. Innovations in Hospice Architecture. London: Taylor & Francis, 2006. Print. 19. Verderber, Stephen, and David J. Fine. Healthcare Architecture in an Era of Radical Transformation. New Haven, CT: Yale UP, 2000. Print. 20. Watt, Chris. “ACC at BJC - Potential Use of VOC.” Personal interview. 9 July 2010. 21. Wotjkowski, Don. “SSM St. Clare Patient Experience.” Personal interview. 24 July 2010.


The Voice of the Customer Toolkit


Voice of the Customer Research  

Research report for Christner regarding how to access the Voice of the Customer and integrate it into the design process.