Patient Experience for Librarians–My Theory On Patient Experience

I thought I would close out the week sharing a few thoughts about one of my favorite subjects, business meetings.  It is difficult to find a good meeting—one that starts and ends on time, one with an agenda, and one with someone who knows how to run a meeting.

Sooner or later, you have to say something, just to appear interested, and to keep someone from saying, “We haven’t heard from you, what’s your take on the fact that aliens appear to be using the men’s room after hours?”  You must keep your head in the meeting enough to make sure you don’t shout out something inane like “You sunk my battleship.”

Most times you can slide by, by just throwing your support behind someone else’s comment.  “Well said Sally.”  Usually someone who was dealt a pair of twos in the looks category will ask you a trenchant question in a dullard’s voice—a voice that tells you that the person speaking won’t be invited to join Mensa any time soon—why you agree with Sally.  In that case, your best defense is to use words with three or more syllables.  It is for that very reason I keep a jar of big words next to me, and interject them as needed.  If you can spit out aberrant and nonplussed in the same sentence, chances are good they will leave you alone.  The less other understand about what you are saying, the less likely they will be to question you for fear they will appear stupid.

I have many of the same issues with presentations, but at least you have slides to look at.

So, back through the looking glass, back to healthcare.  The field of espionage uses the expression walk back the cat.  It means to trace some thing or some event backwards to see what can be learned.

Pick a number between one and ten and throw in two decimal places just for fun.  Now tell the person next to you what your number means or what their number means.  Kind’a tough to do.

It may not mean anything.  Patients who complete a survey, who rate each question on a scale from one to ten, are going through the same exercise, they are picking a number.  What does their number mean?

What does the average of all of the numbers, or their median mean?  Sorry for the double-entendre.  What does it say for those whose scores are two standard deviations away from the mean?

There are two ways to look at improving patient/customer experience.  One way, the way most organizations go about it is to tailor it, person by person, to the requirements of each individual.  Since you can never get to each person to assess their needs, this approach normally fails.

The right way to create a patient experience strategy is to define the requirements of every individual by defining the needs and expectations of a single global patient and a global prospective patient.

Now try coupling that approach to this definition of patient experience—a remarkable experience for every person every time on every device.

Anything less should be unacceptable.  After all, what part of that definition is an organization willing to weaken?  Each weakening means a loss of patients.  Why bother having a marketing and business development group to bring patients in through one end of the funnel if only to have them quickly exit at the other end because of a less than remarkable experience?

Instead of offering a remarkable experience, should we be willing to settle for a pretty good experience?  Should the remarkable experience be available to everyone, or just to most of the people. Every time, or most of the time?  On the phone, a laptop, and a tablet, or just in the hospital?

The existing theory is that all patient experience can be managed through the looking glass of HCAHPs. In order for that theory to work, the theory must become fact.  If it is not a fact then the only alternative is that the theory is wrong.

If you test the theory and the results do not match the theory, do not blame the results, or change how you interpret them.  Change the theory.

Reinventing Patient Satisfaction One Process at a Time

If a blog falls in the woods and nobody reads it does it make a sound?

I was watching the news today and heard the reporter state that the victim was shot in the garage—I guess that is a lot better than being shot in the backside.  My bad, but I am sort of a syntactical enforcer.

When basketball was invented players shot the ball into a peach basket.  When a player scored the game was halted to allow someone to bring over a ladder so the ball could be retrieved from the basket.  The game was very slow.  It was very slow for seven years until someone got the idea to cut the bottom out of the basket.

Suppose someone asks you to give them the Cliff Notes version of Patient Satisfaction.  What is the best way to convey such a complex issue?

There are some 5,000 hospitals in the US.  There are some 2,500 hospitals being penalized for having poor patient satisfaction scores.  As compared to what, did anybody ask the patients?  Use a highlighter or underline this on your monitor—being in the top half of the patient sat scores does not mean that your patients are satisfied with your hospital.

I spoke with one of the chiefs of a large New England IDN. He told me his wife was having surgery, so he arranged for her to have a white-glove experience. Afterwards she raved about the experience.  But, when they viewed her HCAHP survey, her scores did not reflect the great experience she had; they reflected her experience as was defined by the survey.  There is a big difference between the two recorded experiences. In one experience, the one defined by HCAHPS nobody asked her about her expectations, and nobody asked her how she would rate her own experience.

Of the hundreds of thousands of patients who have completed the survey, none of them were ever asked about their expectations. Maybe the survey’s authors did better in Clairvoyance 101 than I. I think a lot of us knew HCAHPS was not the best solution for improving patient experience. Hindsight is a wonderful thing; and the smart people get their hindsight in first.

To the chagrin of the ‘six sigmatists’, here is a news flash.  Shaving thirty-two seconds off of the time it takes to be admitted does not yield satisfied patients.  If making the admitting the process shorter is a good thing, would it not make sense that doing away with the patient admitting process would be a really good thing?  Maybe it is time to cut the bottom out of this peach basket.

There are dozens of other processes for which the same analogy holds water. Improving patient experience may seem a little chaotic, but there are many threads in the chaos, and trying to solve the problem using HCAHPS involves pulling the wrong thread. Is the noise I am hearing the sound of the first pieces beginning to fall into place?  I think the thought behind those who decided to use HCAHPS as the measure of patient satisfaction intended for it to be easy—just a few dozen questions. Instead, it has become like counting votes in Florida.

If your hospital has not recently reinvented how it electronically interacts with patients and potential patients through a world class patient portal, it is way out of touch with how patients interact with other organizations with which they do business.

How would you like to be admitted if you were going to the hospital two days from now?  If you are like me, you would want to navigate to the hospital’s web site the evening before you are scheduled to check in.  You want to pull out your iPad, go to the web site, complete the check in and be given a room assignment.

Patient satisfaction just went up.

I may be wrong but I doubt it.

Patient Experience Lessons From Lubyanka Prison

Lubyanka PrisonAt one time the single word Lubyanka was enough to bring normal Russians to their knees in terror.  Lubyanka is known best for being the headquarters of the Soviet secret police.  The basement of Lubyanka housed a prison which contained one hundred and eleven cells, cells used to hold and interrogate political prisoners during Russia’s purge.

Tea was provided to the prisoners twice each day.  A prisoner within each prison cell would place a teapot outside the cell. A prisoner, carrying a pail filled with tea, would pour tea from the pail into the teapot.

Tea spilled on to the floor.  The prisoner would clean the spilt tea with a rag.

Lubyanka’s prison operated for twenty-seven years.  Tea was served to the one hundred and eleven cells and spilled in front of each cell twice a day, seven hundred and thirty times a year.

Two million, one hundred eighty eight thousand spills.  The same number of cleanups.

Someone somewhere made the decision that it was easier or cheaper to spill and sop the water 2,188,000 times than it was to make pails with spouts on them.

What are the pails in your company?  What dumb, wasteful, redundant activities and processes have been left unchanged?

The most obvious one for most companies is call centers.

It is easier to take 2,188,000 calls each year about your bills than it is to fix the bills.  It is easier to take 2,188,000 calls each year about the bills than it is to get rid of the bills.  The same argument applies to a number of other processes.

And do you know where the fallacy in the argument is?  The fallacy comes from the erroneous belief that by having a call center, by answering calls you are actually providing your customers a service.

You are not.  Most times all you are doing is wiping up spilt tea.

I may be wrong, but I doubt it.

Is Patient Leakage a Black Swan Event?

Several of you wrote and inquired about a term I have used, churn.  Customers churn, and patients churn.  Churn is the opposite of retention.  Instead of being retained patients churn, they go somewhere else.  For those seeking a mathematical explanation, churn is like multiplying retention by negative one.

I am curious to learn if any of us consistently has good customer experiences with the professional services firms we use.  I bet we do not.  We have satisfactory experiences; which we view as remarkable because of the many poor experiences we have.  We have portions of our experience that are somewhat satisfying, perhaps even bordering on good.  Because our experiences in general have degraded over time, what would have been viewed as a poor experience a few years ago now hides behind the veneer of acceptability.  Our standards of what is acceptable have declined right along with the professional services we consume.

Professional services firms include accounting, law, cable, phone, and healthcare, among others.  One characteristic about buying professional services has everything to do with the service; that is why ‘service’ is in the name.

A while ago I spent two days in Nashville at the Loews. Great hotel. The clerk in their lost and found gave me a power cord for my phone. The attendant in the exercise room thanked me for allowing him to serve me during my workout. Sort of makes me feel like I should return the towels—just kidding.  At the end, they asked me, “How did we do?” They didn’t ask about my room, or the food—they knew those things were perfect. They asked about how the people performed. Competing on service.

Hospitals ask about the room.

Last week I rented a car from National.  I always rent from Enterprise.  Enterprise has no perks, no frequent renter upgrades.  I get a car, the same car I could have received from any other rental company.  National gave me a car. I was the only person in line and it took twenty minutes.  I had to initial to form eighteen times.  National’s car was fine; same as what I would have rented from Enterprise. 

I will not rent from National again.  Why?  They did not ask me how did we do?  And how they did was poorly.  Enterprise knows their car will be perfect; they do not need to ask is everything with the car was okay.  Enterprise always asks how they did.  They do not need to ask because their service is always perfect, but they do ask.  They asked how the people performed.  They compete on service, not on cars.  The cars are the commodity.

Most professional services firms know you are no longer a customer because you cancel their service.  Actually, the firm does not know.  It is a closely held secret among you, the person with whom you spoke, the recording of your call—for quality and training purposes–, and the 1’s and 0’s in the computer storing your customer record.

Healthcare is unique in that hospitals never know you are no longer their customers.  Leakage—Roemer defines it as a problem for which you do not know the answer.  Leakage is looked at as a Black Swan event—random and unexpected is a common definition. It is also a definition, that whether intentional or not, hospitals use to explain away leakage.

Permit me to suggest that leakage of a patient—a customer—may be a lot of things but it is neither random nor unexpected. It occurs because somewhere along the way the person (customer and patient) had a bad experience.  The solution is to build robustness against the negative experiences and to exploit the positive experiences.

Robustness is built by actually designing each of the experiences.

Suppose two years ago you, or a family member, had their gall bladder removed at Our Lady of Perpetual Satisfaction.  Or, suppose last week you took your son in for an x-ray for an injury sustained playing baseball, and the x-ray showed that surgery was needed to repair the bone.

The hospital has no way of knowing two very important things.  One, they do not know that you had you appendix removed six months ago at another hospital or that your son had his surgery somewhere else.  Two, they do not know why you chose not to return to them for care.

Look at your call center for example.  It probably closes around 6:00 PM.  Not even Comcast closes at 6:00.  This means from a customer experience standpoint your hospital’s customer’s experience is already worse than that of your cable company.  By the way, that is not a good thing.

For the most part, minus chronic care, every patient is a new patient even though the patient may have been there several times before.  Each time the patient visits a hospital they have a choice about which hospital they will visit.  Unlike cellular companies, hospitals cannot lock in patients for a two-year term.

If hospitals do not know that you left, they will not make any effort to get you to come back.  Since they do not know why you left, they have no way of knowing what they could have done differently that would have caused you to stay.

That makes for a pretty tough business model. It makes it much worse when you realize that the lifetime value of each patient is between $180-$250,000.

The funny thing about being in a services business is that there are always plenty of people selling the same service.  I can probably get my hip replaced or my knee scoped at a dozen hospitals within ten miles of my home.  I believe that no matter which of these twelve hospitals I choose, my hip or my knee will be better when I leave.

I also believe that by definition the service I receive can only be the best at one of those hospitals.

Who among us is competing on service?

Just to throw a metaphorical tomato at the screen, buying patient experience data, or being able to recite your HCAHP scores does not enable you to compete on service.

I may be wrong, but I doubt it

Are Providers Looking In The Wrong Haystack For Needles?

“The time has come,” the Walrus said,
“To talk of many things:
Of shoes–and ships–and sealing-wax–
Of cabbages–and kings–
And why the sea is boiling hot–
And whether pigs have wings.”

Gibberish (I thought Jibberish was spelled with a J) is good, and often insightful.

Sometimes I have to rack my brain to decide what to write; other times it is handed to me, just begging for a response.  This is one of the “other” times.

In the fable of “Chicken Little” the chicken believes the sky is falling because an acorn fell on its head—the chicken was wrong.  In the fable “The boy who cried wolf” the people in the village are fooled into believing a wolf is attacking their village.  The people are wrong.

In the CMS fable “Everything a hospital ever needed to concern itself with regarding patient experience,” CMS is wrong.  And to make matters worse, CMS has all of the providers focusing all of their efforts on catching the wolf.  What many do not recognize is that providers would have been doing these things with or without the hard hand of CMS.

It is much more difficult to find the needle in the haystack when you are not on the same road as the haystack.  Hospitals have already found many of the needles.  Their problem is that the remaining needles are smaller and smaller, and more difficult to find.  Thus, finding each subsequent needle costs more.  Hospitals have also missed the fact that right next to the CMS haystack are other haystacks with needles the size of javelins waiting to be found.

What if two customer experience surveys were compared side-by-side.  One for hospitals and one for hotels.  Might they look like this?





What is the NO. 1 goal of your patient experience efforts?


What is the NO 1. goal of your customer experience efforts?


Improved HCAHPs Scores



retaining customers


Improved clinical outcomes



getting referrals from customers


Improved market share



improved market share


improved word of mouth



improved revenue generation


improved revenue generation



improved reimbursement






No one is arguing that for hospitals to be successful at patient experience that they need to think of themselves as hotels.  No one is arguing that hospitals should stop trying to manage pain or to reduce noise.  The argument is that there are plenty of other things hospitals could be doing to complement their current initiatives, things which would have a much greater impact on improving experience.

What is the business problem hospitals are trying to solve as they wrestle with what to do about patient experience?  Are hospitals trying to create a remarkable experience for every person every time?  If they were their approach would be entirely different.  Are they trying to retain patients, to earn referrals, to capture a higher percentage of their receivables?  If they were their approach would be entirely different. 

The problem hospitals are trying to solve is to avoid the CMS penalty.  Hospitals’ expenditures of people and capital are not targeted to solve an actual business problem; the expenditures are to avoid a problem created for them.

A recent trade journal survey asked, and the article reported answers to the following questions:

  • What is the number one goal of your patient experience efforts?
  • In which of the following patient-related areas do you expect your organization to focus over the next three years for patient experience improvements?
  • Please rank your motivations for investing time or resources to improve patient experience scores
  • Who has the primary responsibility for patient experience in your organization?

The number one goal reported by hospital executives was ‘improved’ HCAHP scores. So, let us assume the hospital achieved its goal and rocketed to the first quartile, thus removing itself from CMS’ penalty.  What do they get from that achievement? Retention, referrals? Nope.

Is this goal an example of keeping ones focus on the hole versus the doughnut?  None of the responses listed any mention of the word ‘patient.’ Less than one in ten respondents addressed improving market share, not that the planned efforts will do much to improve share. And, none of the responses mentioned making any effort to retain patients or to attract prospective patients. 

According to the survey results, hospitals’ primary focus are on trying to meet an artificial benchmark created by CMS without knowing whether achieving this benchmark is the best thing they could be doing to create a remarkable experience for every person every time.

Improving patient experience is an issue that has the attention of most hospitals.  Yet the solutions being proposed seem to be sorely lacking the following initiatives:

  1. Innovation
  2. Transformation
  3. User Experience
  4. Disruption

Who is responsible for the experiences of the prospective patients? Apparently nobody.  Who is responsible for the experiences of people before they come to the hospital, after they are discharged, and of those wondering if they should seek a second opinion from another hospital?  If hospitals cannot agree as to who is responsible for their current assets (patients), then we can be certain that nobody is responsible for the experience or satisfaction of prospective patients (their future assets) or for those patients seeking a second opinion.

The tallied survey responses seem to be all about raising HCAHP scores and avoiding penalties; not about improving the experience or patients and prospective patients.  Does that seem to be the case in your organization?

I estimate that the lifetime value of a patient is somewhere between $180,000-$250,000.  That means that a retained patient and a prospective patient are also worth that amount.  Add to that the revenues of a patient’s family and friends and all of a sudden we are looking at numbers that demand innovation and transformation around patient experience.

Patient Equity Management. Family Equity Management.

A remarkable experience for every person every time on any device.  If this is your goal, the value of having your primary focus be on reducing noise, way finding and better housekeeping, needs to be rethunk.

I may be wrong, but I doubt it.

Patient Experience: I may not be right, but I doubt it.

I just fell out of the stupid tree and hit every branch on the way down. But lest I get ahead of myself, let us begin at the beginning. It started with homework–not mine–theirs. Among the three children of which I had oversight my parenting responsibilities include coloring, spelling, reading, and exponents. How do parents without a math degree help their children with sixth-grade math?

“My mind is a raging torrent, flooded with rivulets of thought cascading into a waterfall of creative alternatives.” Hedley Lamar (Blazing Saddles). Unfortunately, mine, as I was soon to learn was merely flooded. Homework, answering the phone, running baths, drying hair, stories, prayers. The quality of my efforts seemed to be inversely proportional to the number of efforts undertaken. Eight-thirty—all three children tucked into bed.

Eight-thirty-one. The eleven-year-old enters the room complaining about his skinned knee. Without a moment’s hesitation, Super Dad springs into action, returning moments later with a band aid and a tube of salve. Thirty seconds later I was beaming–problem solved. At which point he asked me why I put Orajel on his cut. My wife gave me one of her patented “I told you so” smiles, and from the corner of my eye I happened to see my last viable neuron scamper across the floor.

One must tread carefully as one toys with the upper limits of the Peter Principle. There seems to be another postulate overlooked in the Principia Mathematica, which states that the number of spectators will grow exponentially as one approaches their limit of ineptitude.

Another frequently missed postulate is that committees are capable of accelerating the time required to reach their individual ineptitude limit. They circumvent the planning process to move quickly to the doing stage, forgetting to ask if what they are doing will work. They then compound the problem by ignoring questions of feasibility, questions for which the committee is even less interested in answering. If we were discussing particle theory we would be describing a cataclysmic chain reaction, the breakdown of all matter. Here we are merely describing the inability of most hospitals to connect with the experiences of their patients.

What is your point?  Fair question.  How do we get hospitals and patients to connect?  It appears patients have decided that the current approach (HCAHPS)—will not work.  Thanks for riding along with us, now return your seat back and tray table to their upright and most uncomfortable position.

Putting all of your chips on HCAHPS is a failed plan.  It can’t be tweaked.  We can’t simply add a few more questions to the survey.  We have reached the do-over moment for improving patient experience, or at least the moment when we must acknowledge that while HCAHPS may pass the test of being necessary, HCAHPS are from passing the test of being both necessary and sufficient.  Having reached that moment, let us agree to do something. 

Today’s patient experience efforts rely on an amalgamation of patient experience data.  We have no data about a single patient. We don’t even have data about how a single patient compares to the amalgam. We also have firms that will charge you a lot of money, based on the blended results of your hypothetical patient, to help make the experience of the non-existent patient better.

Need proof? Take blueberries, a mango, two kiwis, and your favorite cheese, pop them into the blender, and hit puree.  Hand the mixture to someone and ask them to describe how a single blueberry relates to the blended drink.  The blueberry and its attributes no longer exists.

Patients, people, and customers want you to know about and improve their individual experience. One way to do this is to ask them, and then to actually design the experience. Design it beginning with the experiences they have before they enter the hospital and include the experiences they have after they leave the hospital. Design it for outpatients, discharged patients, former patients and prospective patients.

By the way, don’t put the cheese in the blender. It will ruin the drink.

I may not be right, but I doubt it.