Patient Experience: You Won’t Believe This Conversation

The entire focus of today’s post is based on a conversation I had with a frontline employee of a prominent health system in the southeast.  This quote is taken directly from our conversation:

“Because our call center is so bad, people do not cal to cancel appointments, they come to the office to cancel their appointments. They rant and rave about their bad experience, and they do it in front of patients who are waiting to check in. And then I get to sit here and listen to them telling their story to the patients in the room, who say they have experienced the same problem over and over, and they ask me why someone doesn’t fix the problem.  The other problem they get when they speak with someone in the call center is they are talking to people with no medical training about their medical problems.  People in our office could answer their questions, but our patients are told to call the call center.”

The best term I have ever heard in any industry for waving the white flag about an unsolvable business problem is healthcare’s term leakage.  It is a word providers use to describe something they believe exists, but have never seen and cannot measure—sort of like when physicists try to explain that each of us exists in a parallel universe.

Leakage often refers to patients who leave their health system and who switch to another provider.  The thing is the provider usually does not know who leaked.  They do not know when a specific patient leaked or why they leaked, and they do not know how many patients leaked. Leakage reminds me of the story of the little Dutch boy who places his finger in the leaking dike and saves Holland. But, in our story, the little Dutch boy is off playing Nintendo, and Holland is flooding.

A lot has been written about the root cause of leakage and suggestions have been made about how to deal with leakage.  I did not come across anything that led me to get excited about the prospects of understanding the problem of leakage or how to fix it.

Before we address the problem, let us make sure we understand why it is so important to stop the leakage.  The average lifetime value of a patient, and of a prospective patient, is between $180-$250,000—use your own value if you think you have a better number.  Therefore, each leaked patient creates a financial loss for your health system of around two hundred thousand dollars.

You know as well as I that if your hospital lost four laptops this week a committee would be formed and there would be a meeting next week to ensure your health system did not lose a fifth laptop.  But if you asked one of the executives what time the Leakage Committee meeting is next week that person would not understand your question.

There is no leakage committee meeting; there is only leakage.  Most health systems think of leakage occurring somewhere after a patient received their care. The patient simply disappears without telling anyone.  It is impossible to prevent someone from leaking if you do not know they leaked.

The two categories of leakage of patients and consumers are:

  • Capture Leakage—Failing to acquire a consumer who is considering purchasing their healthcare from your system
    • Marketing leakage—marketing spends considerable resources to get someone to contact the health system. The person calls and does not get the information or appointment they needed
    • Referral leakage—a primary care physician refers a patient to a specialist, but the patient is never seen
    • Out-of-network losses within an ACO model
  • Stickiness Leakage—Failing to keep a current or former patient
    • Cancellations and no-shows
    • Patients who do not buy healthcare again from your system

My solution to the problem of leakage is to ignore it. Dissolve the leakage committee.

Turn your focus to Keepage.  Treat the people calling your system, the people visiting your website, and the current and former patients as two hundred thousand dollar assets.

Health systems spend several thousand dollars to acquire each patient.  Common sense suggests health systems should spend at least that much to capture and keep the patient.  The best way to excel at Keepage is to make access ridiculously easy and to provide those doing the accessing with a remarkable user experience at a time and on the device of their choosing.

The two channels that account for over ninety-five percent of the attempts to access your health system are the phone (call center) and the internet.

Nobody wants to connect to any company which cannot stop talking about itself long enough to offer something of real value online.  The immediacy, with which your health system responds to a consumer or patient request, and its ability to meet that request, speaks volumes about your system’s interest in keeping the person.

Your health system is probably the most valuable resource in your community, but judging from most health system’s websites you wouldn’t know it.  In the online age importance is measured by the number of visitors to your website and by the number of return visitors.

Do this.  Spend a minute or two on your system’s website and then go to this website,  Scroll down to the bottom and click on the link for its YouTube channel—Will it Blend?  Their videos have been viewed two hundred million times.

Coca-Cola, American Express, and GE also seem to have a pretty good understanding of what it means to be in the business of serving customers.  If you call those companies you will also get the impression that their employees are equipped to handle customers.

Instead of worrying about leakage and patient experience management, develop a keepage program and focus on patient equity management.

CMS Measures HCAHPS, What Do You Measure?

Sharks cannot turn their heads.  Sometimes it seems business leaders have the same problem.  What transformation or innovation would you undertake if you were not afraid to turn your head, to look for solutions if you were not of failing?

Hospitals either have satisfied patients or they do not.  Measuring satisfaction will not yield satisfied patients any more than Comcast’s ‘Customer First’ program got them satisfied cable customers.

Hospital executives do not need satisfied patients.  The term ‘patients’ is a plural, and no patients satisfaction program will satisfy the plural.  The very notion of having a satisfaction program should signify the organization, in fact has, a patients satisfaction problem, which often means it has an access problem.

Permit me a moment of sacrilege.  Forget the patients, or stated better, forget enhancing the satisfaction of the patients while they are in the hospital.  You are already doing everything you can for them. Your doctors and nurses have your patients covered better than any other country on the planet.  What patients complain about is access, but hospitals do not know that because access is not measured, nor is it penalized by CMS.

If a hospital is not to worry about the satisfaction of its patients, how then will it improve satisfaction?  Take out your highlighter and underline the next sentence on your monitor.

Worry about your customer, and worry about whether they can access you–can they do business with you.  Focus on the business processes that affect a single patient/customer.  At least half of patient satisfaction is comprised of things having nothing to do with why the individual is at your facility.  Patients know the clinical experience will not be fun.  They know before they get to the hospital that the clinical experience will likely be painful, intimidating, scary, and perhaps dehumanizing. They accept that. What they will not accept is having those same experiences on the phone.

Health systems assume the satisfaction of patients are tied to whatever clinical procedures they underwent.  That perspective is somewhat akin to the Ritz Carlton assuming the satisfaction of a hotel guest’s entire stay has to do with the success of the presentation they delivered at the Xena Warrior Princess Lookalike Convention.  It does not.  Their satisfaction depends on the cumulative of all of the experiences they had at the hotel.

Your system’s success or failure, the measure of whether a patient will come to you for additional services, whether they will refer other patients, whether they will purchase any services from you has to do with whether you can accomplish basic business processes, processes like scheduling.

People see themselves as customers.  People paying a lot of money for a service.  Their satisfaction includes how much effort it took prior to coming to the hospital and it includes how responsive the hospital was to them after they were discharged.

Health systems do not see people as customers.  The notion of the customer-patient/patient-customer flies in the face of everything of which hospital executives have focused.  It certainly flies in the face of the business processes designed to support a patient-only model.

Here is one way to view the distinction.  Patients get better or they do not.  Getting better, fixing their problem is what the patient expects; anything else is failure.  How that happens is the concern of the hospital.  Came in sick.  Walked out better. Cubs win.

On the other hand, patient/customers are evaluating the rest of their experience.  Patients measure their customer experience from before they check in until after they are discharged.

Total patient satisfaction is the sum of a patient’s patient experience and their customer experience.  HCAHPS only measure a portion of it. It is up to you to create measures for the rest of it. Start with your call center and your phones. If people cannot even schedule an appointment, everything upstream is moot.

Why Is Online Patient Access A Myth?

Two weeks ago Washington announced an agreement in principle with our new best friends Iran to slow Iran’s ability to build nuclear weapons.  I thought we wanted to stop Iran’s ability to have a nuclear weapon, but I was not invited to the meetings.  This week’s television coverage shows a US aircraft carrier shadowing an Iranian ship which is bringing weapons to Yemen’s bad guys the Houthis, the same bad guys who overthrew the US embassy.  Perhaps, since both the Iranians and the US will already be in the Gulf of Aden, the nuclear treaty could be signed on the US aircraft carrier, and the Iranians could cater the affair.  It is only Wednesday, and my gene for being cynical just clicked into overdrive.

The upbeat news however is that on Sunday a 124-pound woman at the Big Texan Stake Ranch in Amarillo, Texas, ate three 72-ounce steaks in twenty minutes, throttling her male competitors—her prior claim-to-fame was consuming 363 chicken wings in 30 minutes. (video link–

Even though healthcare expenditures are not discretionary, customer satisfaction—as measured by the ACSI, not HCAHPS—dropped in 2014.  According to patients, satisfaction for ambulatory services is better than that for hospital services “by a significant margin”, the biggest drop being from outpatient services.

And just to keep things interesting, website satisfaction for both ambulatory care and acute care are below the average website satisfaction of all industries, and on par with the phone companies.  The only industries whose website satisfaction is below those for providers are health insurance and cable television, and provider website satisfaction only beats those two industries by one and two points respectively, an accomplishment that is not worth celebrating.  At least on the websites of cable television operators their customers still have the luxury of subscribing to HBO without having to speak with someone.

The websites of almost every health system have one major thing in common—they are essentially all the same.  Judging by the uniform functionality, I could be convinced America’s health systems built their websites using the same healthcare template.  Their only real differences are the aesthetics of each site.  The colors differ, as does the placement of the common links, but if you’ve visited one hospital’s website, you’ve essentially visited them all.

Usually there is are links for finding a doctor, employees, physicians—they get their own link, careers, donations, locations, videos, baby photos, paying your bill, and if you search long enough you may be able to find the link for patients.  There are also dozens of phone numbers—roulette dialing for a solution.  You may even find a few links that are disguised to make you believe you can complete a task online, links like scheduling an appointment, though they don’t actually let you schedule an appointment.

On the homepage of the website of one major health system in Arizona there are more than 230 links from which to choose.  The average person spends seven seconds on a webpage before giving up.  What chance is there of finding the one link you want if you have to view 230 choices?

There are plenty of things to read on a health system’s website, but there are very few things for a visitor to do other than read.  When I go to a company’s website, I go there to accomplish something. I go there because I do not want to have to call the company.

When I want to read something I buy a book.

Patient Experience Asks: Where’s Waldo?

waldoSeven A.M., Saturday morning on the high school’s outdoor running track.  It reminded me of the way a community swimming pool looks during the time for the adult swim.  A dozen or so older adults were stretching and starting to make their way around the artificial surface of the track.  I hung the bag containing my workout gear on the pole of the chain-link fence. Next to the fence rested several canes and walkers.  I halfway expected to see a box of Depends and a stack of AARP magazines. So this must be what life looks like in the not-so-fast-lane.

After running for an hour I paused and I grabbed my water bottle.  A woman a few years younger than me also reached for her bottle of water. When I asked her how far she was running she said she and her father were running for eight hours. They were training for a one hundred mile run. I almost swallowed my water bottle, but I tried to appear nonplussed. It turns out she and her father, the much older man circling the track, were ultra marathoners. My ego thought about resuming my run but I decided I did not want to die today.

An article yesterday on one of the twenty-four hour news channels mentioned Frontier and Spirit Airlines rated among the worst in customer experience—did anyone need a news article to learn that?  The article went on to mention the two airlines had almost accomplished what many people believed was impossible; they almost managed to rank below Comcast and Time Warner Cable in customer service.  I’m guessing Spirit and Frontier must have had committees working around the clock for months to trying to beat out Comcast—“If we are going to offer bad customer experience, we may as well be the best at it.”  When the results were announced the airline executives tried to maintain a stiff upper lip. “They have not heard the last from us, there is always next year.  We will marshal our resources.  We will cancel more flights and buy smaller seats,” stated an anonymous employee.

Offering a poor customer experience requires hard work.  It doesn’t happen by accident, and it doesn’t happen overnight.  It requires time and dedication.

And it requires indifference. And that indifference starts at the top of the organization.  Leadership either knows the experience is poor and doesn’t care, or it doesn’t know and it doesn’t care.

Improving the access experience should be on every health system’s CEO’s plate. If it isn’t, it is time to get a new plate. Patients don’t leave their health system because they receive poor care; they leave because they perceive their health system doesn’t care.  Doesn’t care about whether they answer your calls, doesn’t care about whether it’s inconvenient for you to call while you are working, or how many times you have to call to schedule an appointment.

That same health system will have a committee studying how to reduce cancellations and no-shows.  They will have another committee performing a root-cause analysis of leakage—patients who disappear.  And they will spend a lot of money on consultants to help them find answers to nagging questions like, “Why did Mr. Waldo skip his procedure today, and why didn’t he let us know? He is scheduled for back surgery in two months. Will he show up for that? What do we have to change to prevent this from happening again and again?”

Here is how to save a million dollars studying how to answer those questions. I think all of the Mr. Waldo kinds of stories went something like this.

Mr. Waldo spent considerable time online educating himself about where to go to have two discs repaired.  He studies hospital websites, reads patient blogs and Facebook, and even watches a few YouTube videos.  And after all of that work he selected your health system.  He called and called, and he eventually made an appointment and saw a specialist.  The specialist gave him a number to call for an initial procedure.  The specialist also scheduled Mr. Waldo for surgery in two months.

It took Mr. Waldo several calls to schedule the procedure. He wasn’t happy. In fact, he was so unhappy with the experience of scheduling the procedure that he skipped it and did not even bother to cancel it.  Mr. Waldo learned that not showing for a procedure meant  he no longer had to waste time calling the hospital; now they called him.  He rescheduled the procedure and completed it.

Two months to go.  The health system reserved the OR, booked the anesthesiologist and the surgeon and the surgical team, and reserved a single room for Mr. Waldo.  While the health system was doing all of those things, Mr. Waldo kept himself busy.  Mr. Waldo knew his surgeon was one of the highest rated surgeons in the city. He read more about the hospital; it was also highly rated.  But his perception was nobody in the hospital really cared one way or the other about whether he gave them his business.  He visited more social media sites, posted his own YouTube video about his experience, and rescheduled his surgery with another hospital.  The only thing Mr. Waldo did not do was to call your hospital and cancel his surgery.

On the appointed day everything was ready.  The doctors and nurses were on standby, the OR was nice and clean, and the single room on the fourth floor—the one that overlooked the Wal-Mart—was ready to receive Mr. Waldo.  The only problem was Mr. Waldo never arrived.  A chorus of “Where’s Waldo?” echoed throughout the hospital.

People, patient people and consumers, people like Mr. Waldo do not like to call a health system any more than you do. Calling requires work. It requires work because calling doesn’t work. It requires multiple calls. And callers often give up their quest before their needs are met.  So when they finally work up the energy to call, it is not to chat.  Their call is important to them in part because it is the only call to a health system they are going to make that day.

Conversely, to the person answering the call, Mr. Waldo’s call, Mr. Waldo is just one of dozens and dozens of people they will speak with that day. This one conversation will be just a blur in their day. It’s not a blur for all of the Mr. Waldos who call each day.  They remember the call.  They tell others about the call.  And then they call some other health system.

What Do Patients Think? The REAL Factors & ROIs of Patient Access

I spent much of the last month asking patients and consumers about what matters to them about patient access.  Why did you do that, you may wonder?  Because I thought somebody should ask them.  There are dozens of firms claiming to be able to improve patient access, but have they asked patients what they think? There are hundreds of health systems claiming to be interested in improving patient access, but have any of their people asked the patients what is important to them?

I learned essentially two things:

  1. The people who want better access include two groups:
    1. Patients. “Patients” means inpatients, outpatients, discharged patients, former patients
    2. Consumers.
  2. Answer your phones, give me the answer I need in one phone call, give it to me by speaking with only one person, and let me call you when I want to call you, not just when you want me to call you.
  3. Allow me to do what I need to do with your organization the way I can with every other firm on the planet with who I do business.

I summarized what I learned in the downloadable PowerPoint deck whose link is below. I would love to know what you think. After all, each of you has been and will be a patient.

Patient Access ROIs

Patient Access: Strike 3, You’re Out!

Equating patient satisfaction with exceeding their expectations is equivalent to equating cosmology to cosmetology. A major reason for the disconnect is providers equate their HCAHP scores as the primary or sole metric for patient satisfaction without ever bothering to see whether those scores matter to their patients. Patient satisfaction has almost no relationship to patient loyalty.

Although patients who call your health system may be satisfied with the result of their call, they are disappointed that they had to call to have their needs met.  Not a single patient ever told a hospital administrator that they selected the hospital because of its HCAHP score or because of the pleasant experience they had calling the hospital.  People do not want to have to call your health system any more than you want to call Comcast or Aetna.  Calling requires effort, and effort makes people look for an easier alternative.

Sixty percent of the people who call a provider are calling because they could not solve their problem by going to the provider’s website.  Strike 1. The fact that the vast majority of provider call centers are really just scheduling centers further erodes patient loyalty. This happens because only about twenty percent of the calls are about scheduling.  The other eighty percent of the calls have to be transferred.  Strike 2.  The average caller has to make more than two calls to have their needs met.  Strike 3.

Let’s consider an example.  Suppose the marketing department launches a campaign to acquire new patients, or to get current patients to purchase a new service—appendectomies half-off.  Now nobody seems to know what it costs to acquire a new patient, but let’s assume that it is not cheap.  The prospective patient sees the marketing campaign on a billboard or hears about it on NPR or sees a flyer taped to the door of a hospital elevator.

That person goes to the provider’s website to sign up for the service, but there is no information about the campaign online.  Strike 1.  They call one of the many numbers on the provider’s homepage and ask Sally about the campaign.  Sally does not know about the campaign and transfers the caller.  Strike 2.  Pete answers the transferred call.  Pete works in radiology and has no idea why the call was transferred to him.  Strike 3.  The provider struck out, and chances are good that the person who called will not call again because calling requires too much effort.

Providers create loyal patients by solving their problems quickly and easily.  What does the term ‘easy’ mean in context of this discussion?

The provider’s perspective of easy: We make it easy for you to solve your problem. We give you a number to call—they usually give you dozens of numbers to call—and we give your 45 hours during which you can call.

The patient’s perspective of not easy: Our only alternative is to call, and we can only call Monday through Friday from 8 A.M. until 5 P.M.

What do patients and prospective patients—consumers—consider access easy?

  • Contact at any time
  • Contact on any channel; web, phone, chat, email

Eliminating the requirement that people have to call your organization to meet solve their problem also solves their single greatest complaint about their experience.  Not having to call once eliminates the need of them having to call more than once.

Many health system executives believe their website offers patients an easy alternative to calling to solve their problems.  Having a link reading ‘Schedule an appointment’ that simply provides a form for someone to complete to ‘Request an appointment’ does not actually let the person schedule an appointment.  Neither does ‘Request your Health Record’ if it only takes you to another form.

Patient Experience: Is It Real Or Imagined?

The seventies was an interesting decade to say the least. Bellbottom pants, platform shoes, long hair, and necklaces were the fashion of the day, and that wasn’t even the girls.  It was also the decade of technology, a technological boom that would never be equaled.  Slide rulers were replaced by calculators, analog watches were replaced with digital watches, music became portable with Walkmans,  your phone could be carried around the house, you could record missed calls, and you could punch a button and change the channel of your television.  Radio Shack and Texas Instruments would soon rule the business world Life was good.

I studied mathematics in college and learned about imaginary numbers. The simplest imaginary number i is equal to the square root of negative one.  The thing about imaginary numbers is that they do not exist, they are imagined.  But once you define the thing your imagination has imagined, you can do things to it. You can multiply it and divide it and tell others about it.

John Nash is the Princeton mathematician about whom the movie Beautiful Mind profiled.  Nash created an economic model about game theory and he was awarded the Nobel Prize for work showing that when multiple players are involved, for the group as a whole to win every player must choose a path that is not optimal for them, but that also does not put them in a losing outcome.  They must choose a suboptimal outcome, one that allows everyone to benefit. Part of his equation is shown below.


The point of showing this equation is to recognize that if any single variable is removed there is no equation.  By definition, both sides of an equation must be equal.  A missing piece invalidates the whole.

Health systems have their own mathematics and their own imaginary number i.  It is most frequently imagined and used to calculate Patient Experience; cal it PXi.

The traditional mathematical patient experience equation is the following, and you can tell others about it and make believe it is real:

PXi = HCAHPS (experiences of inpatients in the hospital)

Problem solved—not so fast Skippy.  The health system formulation of PXi fails because it does not include many of the variables comprising patient experience. It does not include a single experience that happens prior to treatment and after treatment. Oh, and it does not include the experiences of the majority of a health system’s stakeholders; namely outpatients, discharged patients, former patients,  family members, and the largest group of all, consumers—prospective patients.

So the real formula for patient experience is:

PX = (hospital experiences for inpatients and outpatients) + (stakeholder pre and post-hospital experiences)

Please notice there is no i in the real formula because the formula no is longer an imaginary number.  The PXi formula also fails because its calculations are based on measures tied to what CMS feels are important.  Although HCAHPS claims to represent the experiences of patients, the single most important measure missing from the CMS formulary is it does not include the perspective of a single patient. Nobody every validated the survey questions against what patients feel makes a good experience.  And therein lays the rub.

Although imaginary numbers have their place in mathematics, they are of little value in healthcare.