MARKETING REVIEW

INTERNAL MARKETING BUILDSSERVICE QUALIHBy W. Benoy Joseph

M./ / "^ Jfy elderly father was hospital-ized after he had a stroke. My

.Mom and I took turns stayingin his room with him. One early morning, myDad needed to go to the bathroom. I startedhelping him hut lost my balanee, and he almostfell on me. I rang the nurse's desk for help.

"'Yes, sofneone will be there.' the voieeanswered. I was trying hard to support myfather who is a heavy man. Three minuteslater I rang for the nurse again.

"The voice on the intercom said: 'Yes, weknow. Someone will be there.'

'"But you don't understand, this really isan emergency I' I pleaded.

"'Ma'am, we'll help you in a few minutes.We're having a shift change.'

"Oh, I just hate that place."A hospital executive heard this true

story second hand from a friend. Thehospital in question—a large researchand teaching institution—competeddirectly with her equally large tertiarycare hospital. Yet she winced in embar-rassment. Even though the competitor'sexternal marketing programs were theenvy of everyone in the local health carecommunity, something was obviouslywrong. The executive knew this problemwas internal and, if left unchecked, coulddo serious harm to that hospital's reputa-tion.

When consumers in a national Gallupsurvey were asked what "quality in ser-vices" meant to them, one-third of allresponses, the largest group, cited employ-ee contact skills such as courtesy, attitudeor helpfulness (American Society forQuality Control 1988). Winning your cus-tomers over and building a reputation forquality cannot happen if your employ-ees—your internal customers—do not per-form to expectations or subscribe to yourphilosophy of customer service.

Indeed, for service businesses such ashealth care that are labor-intensive anddemand high levels of personal contactbetween the service provider and the cus-tomer, no marketing plan can be consid-ered complete unless it includes strategiesfor reaching and winning over its internalcustomers.

Internal marketing seems simple andcommonsensical: After all, what can bemore self-evident than the logic that,when treated right, employees will treatyour customers right. However, there ismore to internal marketing than meets theeye. Where does it fit within an organiza-tion's marketing plan, or, indeed, withinits strategic plan? What are its bound-aries? Who should do it—marketing orhuman resources? What importantlessons about internal marketing canhealth care organizations learn from otherindustries? What does the diverse litera-ture on this topic tell us?

This article explores these and otherquestions and attempts to relate the evi-dence and thinking from the marketingand management literature to health careorganizations.

Defining Internal MarketingInternal marketing has been defined as

selling the firm to its employees (Gronroos1981) or the process of "attracting, devel-oping, motivating, and retaining qualifiedemployees through job-products that sat-isfy their needs" (Berry and Parasuraman1991, p.l51). George and Gronroos (1991)maintain that the "internal market ofemployees is best motivated for service-mindedness and customer-oriented behav-ior by an active, marketing-like approach,where marketing-like activities are used

internally" (p. 86). Kotler and Armstrong(1991) view internal marketing as thebuilding of customer orientation amongemployees by training and motivatingboth customer-contact and support staff towork as a team (p. 607).

Clearly, such a proliferation of defini-tions merely underscores the growinginterest among service providers to getemployees to adopt the marketing con-cept of customer orientation and tobecome part of the company's team.However, a parallel but even more signifi-cant movement must be noted which res-onates in discussions of internal market-ing: the drive to improve quality.

Building a Culture of QualityInspired by the seminal works of

Deming (1982,- 1985), Juran (1989), andCrosby (1979), manufacturing and servicebusinesses worldwide have adopted pro-grams with such familiar acronyms asTQM (total quality management) or CQI(continuous quality improvement). Eventhough these terms are largely alike, CQIis preferred over TQM because it is moreinclusive of all workers and eliminatesthe suggestion that quality is only the jobof managers. Hospitals and other U.S.health service organizations, rocked bymassive environmental changes (e.g., costcontainment; alternate delivery systems;new reimbursement policies; managedcare), have been forced into exploringCQI and allied strategies for survival.

However, buying into the so-calledquality culture is not always voluntary.The Joint Commission on Accreditation ofHealthcare Organizations (JCAHO) hasmandated that hospitals seeking accredi-tation also invest in CQI-type programs.In 1990, JCAHO's philosophical agendaemphasized the following key priorities:

5 4 Spring 1996 — Vol. 16, No. 1

• Organizationwide devotion to qual-ity—leadership involvement in pro-moting and improving quality.

• Customer orientation—attention tocustomer needs; feedback frominfernal and external customers;customer- supplier dialogue.

• Work processes that incorporatesystems approaches and cross-func-tional teams.

• Measurement and use of data toidentify underlying causes.

- Never-ending commitment toimpro\'ing performance.

Two key tenets of the CQI philosophyfurther inform our understanding of theimportance of internal marketing, espe-cially for hospitals and other health ser-vices organizations:

• Quality is not the responsibility ofjust one department or individual;it is organizationwide and involvesall members of a service organiza-tion (American Hospital Association1990).

- "Delivery quality" in health ser-vices refers to "ali aspects of theorganization's interaction with thecustomer in delivery of output"(James 1989, p. 11)

Expanding the DefinitionDrawing from these perspectives, T

offer the following expanded definition ofinternal marketing: "Internal marketing isthe application of marketing, humanresources management, and allied theo-ries, tecliniques, and principles to moti-vate, mobilize, co-opt, and manageemployees at all levels of fhe organizationto continuously improve the way theyserve external customers and each other.Effective internal marketing responds toemployee needs as it advances the organi-zation's mission and goals."

This revised definition reminds us thatinternal marketing is both customer-focusedand employee-focused. Marketing has noexclusive claims to this important market-ing function; it demands an integrativeapproach, drawing not just from marketingbut also from organizational bebavior,human resources management, and otberfields.

This definition also alerts us that theterm "customer orientation" should be

broadened to include external as well asinternal customers, the latter being anydepartment or unit that is served byanotber unit within the same organization(e.g., a hospital's pathology laboratoryserving oncology). Gremler, Bitner, andEvans (1994) report thaf an employee'ssatisfaction with his or her service firmcan be significantly influenced by serviceencounters experienced with internal ser-vice providers.

Internal marketing, then, is not just forfront-line employees, important as theymay be to the delivery of quality serviceto ultimate consumers. Albrecht andZemke (1985) sum it up best in tbeir pop-ular best-seller. Service America! as theyadmonish all workers and managers inservice organizations: "If you're not serv-ing the customer, you'd better be servingsomeone who is" (p.108).

Nature of ServicesCross-Functional Integrations

Services marketing and managementpose special challenges because servicesdeal witb "processes ratber than things,with performances more than physicalobjects" (Lovelock 1992, p. 17). Threemanagement functions—marketing, oper-ations, and human resources—are inti-mately joined in what Lovelock hasdubbed the "service trinity/' to create anddeliver services.

In health care services delivery, thisfunctional integration can appear almostseamless. For example, the emergency-room physician is responsible for produc-ing, delivering, and "marketing" the ser-vice to the patient during the consulta-tion. If the patient waited too longbecause the ER was understaffed, tberesulting cu.stomer dissatisfaction is amarketing problem, but one that must beaddressed at the operations and humanresources management levels as well.

An ER's unpredictable demand condi-tions can result in crowded waitingrooms, ER staff who are under stressbecause of overwork, medical or test pro-cedures that may be less closely moni-tored than usual, and unhappy patientsand their families. And, if the attendingphysician fails to apologize for the delayor—worse—is perceived as rude, servicequality will again be compromised even ifthe clinical outcomes were successful.Services produced by people are oftenindistinguishable from the persons deliv-ering the service: The hospital and all thatit represents is embodied in the ER's

front-line workers: the receptionist, theparking attendant, the triage nurse, andthe attending physician, among others.

Internal marketing recognizes this vitallink by focusing on the people componentof the services management "trinity."

Moments of TruthA considerable body of research in the

marketing literature has focused on the"service encounter," which is defined as"the period of time during which a con-sumer directly interacts with a service"(Shostack 1985, p. 243). ScandinavianAirlines System's Jan Carlzon once esti-mated that, with 10 million customerscoming in contact with approximatelyfive SAS employees for an average of 15seconds each time, the companv was "cre-ated" in the mincis of customers 50 mil-lion times a year. Carlzon suggested thatthese 50 million "moments of truth" werethe "moments that ultimately determinewhether the company will succeed orfail...when we must prove to our cus-tomers that SAS is their best alternative"(Carlzon 1991, p. 425).

Every episode where a customer orkey buying influence interacts with a ser-vice company, its products, people, facili-ties, or communications represents amoment of truth because each episodecan shape a customer's impressions andjudgments about the firm. In health caresettings, service encounters involve aIiigh degree of interpersonal contact andinteraction between the front-line serviceprovider and tbe patient or the patient'sfamily (Solomon, Surprenant, Czepiel,and Gutman 1985).

Carlzon's memorable pbrase forceshealth care managers to define their ser-vices, not in broad, sweeping images ofhigh-tech medicine and glossy newslet-ters, but in terms of dozens—perhaps,hundreds — of specific encounters orevents (e.g., admission, food quality, staffresponsiveness, discharge, telephoneinquiries, etc.).

Employees shape these moments oftrutb, not only by the tasks they perform,but also by the way they look, act, talk,and interact with the customer, with othercustomers, and with fellow workers.Employee behavior must therefore becarefully orchestrated and managed.

In high-contact service encounters,such as those in health care delivery, ser-vice production and consumption oftenhappens simultaneously — in real time.Managing these moments of truth is notunlike staging a performance or play, onewhere the actor's script is fluid or impro-

Journal of Health Care Marketing 55

EXHIBIT I

The Relationship Marketing System in a Health Care Organization

Internal organizationalmarketing

Backstageemployees& depts.

Internalinter-unitmarketing

Front-lineemployees

Extenml"customers'

Production Consumption

Patients

Patients' families

Referring physicians

Other hospitals

Payer^man^ed care

Donors

Government

Clinical staffAdministrative staff

Technical/support staffVolunteers

visable but the audience also participatesin shaping the plot.

Dramaturgy in Service DeliveryTlie theatrical performance has ser\'ed as

a powerful metaphor for the rules that gov-ern effective social interaction (Goffman1959) and effective service performance(Grove and Fiske 1983). In service settingsthat require high levels of personal contactwith the customer, the dramaturgical per-spective suggests important codes of con-duct for service marketers and their "castmembers" (i.e., the service workers):

Preserve the Illusion. Skilled actorsand stage crew—along with well-designedsets—create an illusion for the theateraudience. Chaos may reign backstage butthe actors on stage will never let on; theywill follow their scripts and stick to theirroles. Service delivery is no different.

The services marketer must be atten-tive to the appearance and behavior offront-line workers—how they are dressed,how they speak and what they say (their"script"), and their facial expression,demeanor, and personality. Attributes thatare inconsistent with the intended imageshould be concealed or underplayed.

Front-line workers must stick to theirscripts (e.g., personal frustration with amalfunctioning computer or an irate cus-tomer should be concealed; siang or pro-fane language used backstage shouldnever be used in front of customers).

Be Loyal. Cast and stage crew mustwork as a team to put on a show. Actorsmust be loyal to eacli other as they playtheir parts and never disclose secrets oftheir performance to the audience. If anactor forgets a line, the other actor mustplay along, and never act surprised or letthe audience know about the slip. Such dra-maturgical loyalty is essential among ser-vice workers who must often work inteams. Team loyalty, however, should notsupersede ethical considerations such aswhistle-blowing when team members arenegligent or make serious mistakes.

Orchestrate the "Performance." Goodplanning and coordination, proper "cast-ing" (determining the right roles to beplayed by frontstage and backstage mem-bers of the service team), and advanceknowledge about the "audience" or cus-tomers to be served can help ensure a suc-cessful service encounter or performance.

Grove and Fisk (1983) suggest that thedramaturgical perspective may be of specialvalue in two types of service settings: (1)where many people are served simultane-ously rather than individually and (2) wherethere is a high degree of contact between theservice provider and the customer.

Health care services fit both categories.Certainly the presence of teamwork andcareful discipline in following a script andsupporting each other are vital to the effec-tive delivery of a wide range of health ser-vices that are provided by hospitals, clin-

ics, health and wellness centers, intermedi-ate and long-term care facilities, andurgent care centers where many customersare served concurrently.

Yet the dramaturgical imperativeswould be no less critical to the effectiveperformance of professionals and supportstaff in dozens of settings where health ser-vices are individualized (e.g., primary carephysician or dental practice, surgery cen-ters, physical therapy, counseling services).

Energizing and motivating your "cast"of front-line and backstage workers is animportant part of the internal marketing

Internal Marketing IssuesIn health services delivery, the pivotal

role of the front-line worker in deliveringservice that is consistent and of high qual-ity can be the organization's biggest com-petitive asset. However, the human factorcan also be its most tenuous and vulnera-ble competitive feature.

Well-trained and dedicated staff canenhance the patient's service experienceand contribute significantly to the organi-zation's reputation for responsive service.But high employee turnover, inexperi-enced new employees, and low moraleamong members of the professional staffcan undermine the organization's perfor-mance during each service encounter.

56 Spring 1996 —Vol. 16, No. 1

Where and how does internal market-ing fit into the marketing operations of ahealth services organization?

Relationship BuildingOver the last dozen years, marketing

thinking, especially for services, has shift-ed from a transactional to a relation-ship-building orientation—the formerbeing short-term goal-oriented and thelatter long term (Berry 1983). Gronroos(1995) offers a pithy description of the dif-ferences between the two approaches:"...[T]he goal of transaction marketing isto get customers, whereas the goal of rela-tionship marketing is to get and keep cus-tomers" (p. 253).

Internal marketing is viewed today asan integral part of a service business'scomprehensive plan for relationship mar-keting', with the other components oractivities being external marketing (reach-ing and serving traditional customers andother external publics) and interactive mar-keting—that which occurs during a serviceencounter, the moment of truth (seeGronroos 1990; Kotler 1994; Bitner 1995).Exhibit 1 summarizes how these marketingcomponents interrelate for a hospital orother health services organization.

There are some obvious parallelsbetween conventional consumer market-ing and infernal marketing: Both arebased on the concept of exchange andboth require efforts that help to persuade,inform, and change behavior. However,several unusual features about internalmarketing require managers to thinkresourcefully, creatively, and integrativelyin order to reach and influence the organi-zation's diverse range of internal cus-tomers—from some who are highly influ-enfial (e.g., physicians, administrators,program heads) to others who performmenial, yet no less important tasks (e.g.,housekeeping or back-office work).

Integrative Features

Successful external marketing is cus-tomer-focused in driving sales strategy.Successful internal marketing isemployee-focused, with the ultimate goalof building effective service strategies thatserve external customers. Winning inter-nai marketing programs, then, can besummed up in the following deceptivelysimple but challenging set of tasks: recruit,train, motivate, communicate, and co-opt.

Recruiting is analogous to segmenta-tion and target market selection in con-sumer marketing. Training, motivating.

and communicating are analogous to mar-keting mix decisions that facilitate theexchange between the organization andthe employee and maximize its perceivedvalue. And co-opting is the process of rela-tionship building—to enhance morale,pride, loyalty, customer orientation, and asense of ownership among employees,similar to consumer brand loyalty.

Target Market SelectionRecruit Aggressively and Creatively.

Good employees must be sought out andrecruited. Reward successful referrals. Eorlower-level positions, explore alternativepopulations (e.g., the elderly, disadvan-taged, mentally retarded, or physically dis-abled). Offer attractive compensation plansand, if needed, flexible work arrangements(e.g., flextime, job sharing) to attract work-ers with desirable skills (Davis 1991).

Select and Screen. Not every person iscut out for service jobs. Reichheld (1993)maintains, "Just as it is important to selectthe right kinds of customers before tryingto keep them, a company must find theright kind of employees before enticingthem to say" (p. 68). Employ screeninginstruments such as video-assisted testing(Jones and Decotiis 1986) and quasi-per-sonality scales such as the "service-orien-tation index" (Hogan, Hogan, and Busch1984), which help to identify workerswho may be strong or weak in interper-sonal social skills. The SOI scale, tested onnurses in a hospital and a nursing home,reportedly proved to be a valid predictorof interpersonal behavior on the job.

Train and Socialize. When systems failor quality slips in people-based services,it is usually because the system is badlydesigned or the workers were poorlytrained. Training budgets should be dri-ven by strategic goals and organizationalrealities, not on wbat is affordable orwhat is left over after basic expenses havebeen covered.

Ritz-Carlton, a 1992 winner of the presti-gious Malcolm Baldrige National QualityAward, credits its success to its more than10,000 employees, spread throughout 27 prop-erties (Eisman 1993). Coaching people in theRitz-Garlton way of life begins even beforethey start working there. Every applicant isinterviewed three times before being offered ajob, and then spends two days in an orienta-tion class. Personal interaction and companyphilosophy are emphasized. Ritz-Carltonemployees recei\'e 100 hours of quality train-ing a year, which includes the time spent inproblem-solving teams. Disney World putsnew employees ("cast members") throughextensive orientations and socialization pro-

grams at its training school, Disney University.Even highly educated professional

staff members need to be trained on thedramaturgy and proper scripts that vari-ous service encounters demand. Frequenttraining and follow-through can meanmore consistent service performances,more successful moments of truth, lessrole ambiguity and job stress, and moresatisfying work experiences for the ser-vice provider.

Bridge Language/Cultural Gaps.Cultural diversity is a reality in many hos-pitals and other large service organiza-tions. But diversity poses special problemsin service delivery. Sometimes, employeesmust be socialized into the culture of theorganization. Asian or European physi-cians and other health care workers, forexample, may be linguistically as well asculturally challenged.

Lack of eye contact while speaking or apassive, reserved demeanor, considerednormal in another culture, may seemunfriendly or hostile to Americans. Theinability of a nurse or physician to commu-nicate in colloquial American English canleave American patients or their familiesfrustrated. Training in culture and languagemay be almost as important as the technicalmedical training fhat is normally expected.

Segment and Understand Employees.Motivation and sources of satisfactionvary among employees. Professionals,such as physicians or researchers, may bemotivated by professional affiliations andpeer recognition. Personal and family fac-tors can influence the quality of work per-formed. Race and cultural differencesmust be recognized as potential sourcesof workplace stress. The motivational dri-vers of the various employee segmentscan help in developing the right programsand rewards.

Building Internal SatisfactionListen to Internal Customers. Use focus

groups and employee surveys periodicallyto gauge morale, satisfaction, and generalattitudes toward work and the organiza-tion. Customer satisfaction surveys shouidbe validated with employee surveys for acomplete picture. The Cleveland Clinic, amajor tertiary care center with nearly 500physicians, conducts a physician peerreview survey that enables physicians toreceive anonymous feedback on the servicethey provide to colleagues in other depart-ments (Gombeski, Day, Fay, and Lowery1992). Survey feedback not only helps toimprove technical quality, but also servesas an internal marketing and managementtool for physician managers.

fournal of Health Care Marketing 5 7

Involve, Empower and Enfranchise.Experiment with quality circles, sugges-tion programs, and employee surveys ofservice quality (Davis 1991). Rewardemployees when suggestions are adopted.Empower them with information andrewards based on company performance,and give them the authority to make inde-pendent decisions that can advance theorganization's mission (Bowen and Lawler1992; Kelley 1993). Empowering makesemployees more customer-focused,responsive, and responsible and improvesmorale and self-image (Bateson 1995).

Get Senior Management to the FrontLines. Peters and Waterman's bestseller.In Search of Excellence (1982), noted thatsenior managers in America's best com-panies stayed "close to the customer" byregularly visiting customers or accompa-nying field reps on sales calls. At DisneyWorld, all managers take part in an annu-al "cross-utilization" program in whichthey perform various basic service tasksin the theme park, such as loading ridesor selling tickets (Bateson 1995, p. 266).

In health care organizations, senioradministrators must get close to theirinternal customers by serving periodicallyin backroom and front-line operations(e.g., in laundry services or a hospitaladmitting room, in a nursing home's din-ing room during meal times, or in anemergency medical service ambulance).Indeed, service employees at all ranks canlearn to appreciate the patient's as well asinternal customers' perspectives by par-ticipating in role playing exercises thatsimulate a service encounter

Foster Team Spirit. Deming (1986)urged managers to "break down the classdistinctions between types of workerswithin the organization—physicians, non-physicians, clinical providers versus non-clinical providers, physician to physi-cian..." (p. 202). Team spirit and participa-tive tendencies are enhanced when sin-cere efforts are made to remove the sym-bols of rank (e.g., executive dining roomsand rest rooms, preferred parking spaces)that have traditionally heightened thesense of alienation between managers andworkers and between high- and low-ranking medical professionals.

Commimicate Fonnally and Informally.Employee newsletters and e-mail announce-ments continue to be popular and effectivevehicles for reaching internal customers.However, creativity and originality areessential to building and maintainingstrong readership. Credibility is important,occasional setbacks in addition to successstories can win readers and lessen the com-

pany newsletter's image as a top manage-ment mouthpiece. Mass media advertisingthat features employees can strengthenemployee morale and company pride:MCI, Delta Airlines, and Wal-mart featureemployees regularly.

Sharing information—including orga-nizational plans and decisions—withselected groups of workers can heightenthe spirit of trust and partnership that isso essential to people-based services.Employees can feel disenfranchised, andrightfully so, when news about importantpolicy decisions affecting them (e.g.,mergers or cutbacks) is first learned fromthe morning newspaper rather than froman internal communique. However, open-ness must be tempered with discretionand judgment; bad news about imminentlayoffs, for example, must be handledwith infinite care.

Co-opting Good EmployeesAccording to Webster's New World

Dictionary, to co-opt is to persuade or lurean opponent to join ones own system orparty. Executive orders may producereluctant compliance among employees;logical explanations and persuasive argu-ment may result in cooperation; co-opta-tion, however, is when employees buyinto or take ownership of an organizationand its plans.

Co-optation is analogous to conversionor acculturation: Employees subscribe tothe philosophy and culture of the firmand their values coincide with those ofthe organization. When a service organi-zation achieves this level of employeeinvolvement and commitment, its internalmarketing can be held up as an exemplarof effective relationship marketing.

Admittedly, such achievements do notcome without considerable mutual invest-ments by both employees and the organi-zation. What can be done to win over youremployees? The following approacheshave been suggested by management the-orists and practitioners (e.g., Davis 1991;Bowen and Lawler 1992; Henkoff 1994;Heskett, Jones, Loveman, Sasser, andSchlesingcr 1994; Rothman 1993):

Financial Rewards. Tie bonuses,rewards, and recognition to performance,exceptional customer service, length ofservice, and group or departmentalachievements. In for- profit organizations,explore profit-sharing and employeestock option plans.

Expand/Open Career Paths. Provideand promote opportunities for advance-ment through retraining and tuition reim-bursement programs. For low-level, pri-

mary- care staff (e.g., in home healthcare), these benefits can help to improvemorale in so-called "dead-end" jobs anddecrease worker turnover. Support pro-fessionai staff with funds for professionaldevelopment, certification, and continu-ing education.

A midwestern hospital is assistingnurses to attend MBA programs; recog-nizing the problem of physician burnout,a college near Atlanta has introduced aweekend MBA program strictly for physi-cians. For technical staff, offer dual-careerladders.

Support Diverse Employee Lifestyles.Consider the costs and benefits of offeringservices such as on-site daycare, elder care,flextime, transportation, cafeteria-stylebenefit packages, and employee assistanceprograms (counseling services, help foremployee or family members for sub-stance abuse, etc.).

Taking ResponsibilityClearly, several departments may be

involved in internal marketing, but princi-pally human resources and marketing. Theactivities and philosophies described herehave a strong human resources focus (e.g.,recruitment, motivation, career advance-ment, etc.). Other areas (e.g., scripts, dra-maturgical dimensions, employee commu-nications) have a promotion and market-ing focus.

As one might expect, internal market-ing must be done by both departments—and by many others. In health serviceorganizations, every department head,office manager, supervisor, chairperson,and middle- or upper-level manager mustbe an internal marketer.

But, just as in external marketing,where a market manager or industry spe-cialist is made responsible for servingspecific market segments (e.g., an insur-ance company has executives who spe-cialize in employee benefits and otherswho specialize in life or automobile insur-ance), internal marketing needs a champi-on to get the job done.

The internal marketing coordinator,manager, or director should work withhuman resources, marketing, public rela-tions, and the various department heads tomake internal marketing work. This posi-tion should report to the executive directorin small organizations or to the vice presi-dent of marketing or strategic planning inlarge organizations (I recommend a mar-keting affiliation because the ultimate out-comes being sought here are driven by

Spring 1996 — Vol. 16, No. 1

customer and market considerations ratherthan human resources considerations).

Critical LinksHeskett and his colleagues (1994)

describe the "service-profit chain" as therelationships between profitability, cus-tomer loyalty, employee satisfaction,employee loyalty, and productivity. Thelinks in this chain suggest that profit andgrowth are stimulated primarily by cus-tomer loyalty, a direct result of customersatisfaction, which is largely influencedby the value of services created by satis-fied, loyal, and productive employees.

Employee satisfaction, in turn, results pri-marily from high-quality support servicesand policies that enable employees todeliver results to customers.

Service employees—from the lowest tothe highest levels of the health care orga-nization and frontstage or back—are criti-cal links in this chain. Proactive andwell-designed internal marketing pro-grams can reinforce and temper these

links in delivering consistently superiorservice.

Endnote^ See the Fall 1995 Special Issue on

Relationship Marketing in the journal of theAcademy of Marketing Science, Vol. 23, No. 4,for a comprehensive treatment of this topic.

About the AuthorW. Benoy Joseph is Associate Professor and Chairman of the Marketing

Department at Cleveland State University.

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