Patient Access: What Does Failure Cost?

It is time we pull back the curtain and tell the truth about patient access and scheduling. The points of truth are:

  • Almost all access happens by phone
  • Most health systems do not have a “call center”. What they have is a room with a lot of phones and a lot of people whose job is to schedule appointments
  • Less than thirty percent of inbound calls are about scheduling
  • More than seventy percent of calls are transferred into a black hole where call resolution cannot be measured
  • Of the scheduling calls, only about 59% are completed on the first call

Just so we are on the same page when it comes to measuring how bad is bad, the cable television industry only transfers around 11% of its calls. Scheduling a healthcare appointment takes about 60% longer than it takes to schedule a cable appointment. If scheduling a healthcare visit at your health system is more disappointing and less productive than scheduling an appointment with Comcast, if you have to up your game considerably just to be able to state “we are just as good as the cable company”, then alarm bells ought to be going off in somebody’s office.

After all, people do not need cable, but they do need healthcare. On average, an astonishing 30% of callers who do not have their needs met will not call back. They will not call back, but many of them will head straight to the ED. That’s an expensive cost to pay for not being able to manage a phone call.

Twelve percent of people who have to call more than once will change their provider—now there’s an easy way to understand one component of leakage. At an average lifetime value of a patient of between $180-000 to $250,000, a health system should calculate the loss of these assets in the millions of dollars. Again, that is an expensive cost for not being able to manage a phone call.

In most industries, the measure that has the greatest impact on customer satisfaction is first call resolution; were the caller’s needs met the first time they called? There is actually a one-to-one correlation—increase first call resolution by two points and customer satisfaction increases by two points. And did I mention that a part of the Affordable Care Act has to do with patient satisfaction?

So, if that news isn’t bad enough, permit me to raise the angst bar even higher.

People used to say things like I have to go to the doctor. That phrase is falling out of favor because people no longer have to go to the doctor. They can go somewhere else when they are not feeling well. Last year, my family went to the CVS Minute Clinic thirteen times. We went to the doctor three times, and we only did that because the nurse at the Minute Clinic recommended we see the doctor.

How many times did I have to call the Minute Clinic to schedule an appointment? How many times did I have to pull out my credit card, or call to get someone to explain the bill? How many times did I have to make an extra trip to get my prescription filled?

None. It is like hitting the Easy Button.

None of your patients wants to work hard to give you their business. None of them want to work hard to have their needs met. So why not design patient access and patient experience so people do not have to work hard?

CVS, and all of the other healthcare retailers, did one thing that your health system did not do, and it shows. They designed the access experience. Instead of saying how do we make scheduling an appointment easier and faster—a six-sigma approach—they eliminated scheduling.

And please note, from a patient’s perspective every health system has its own version of the Minute Clinic. It’s called ED.

Patient Experience: Duty, Honor, Country

Every fast food restaurant has a menu item called a Number 1, none of them start their menus with an offering called a Number 2.  And the Number 1, is always the most ordered item simply because it is first.  In most instances, being first is good.

This weekend I watched a fascinating documentary about the annual Army-Navy football game. Just to be transparent, I should note that I attended the other military academy, the Air Force Academy. To say I attended it is a bit unfair to what these young men and women did; I stayed long enough for several haircuts. The Midshipmen and the Black Nights featured in the documentary really attended.

During the two-hour presentation, an important phrase was stated, one that could have easily been missed unless you were paying attention closely. Cadets and midshipmen alike mentioned that their goal for the game was to sing second.

Sing second. Those two words are sewn inside the uniform collars of Army’s football jerseys. One of the many traditions of the game is that at its conclusion the two teams, along with the entire corps of cadets from each school, out of mutual respect and admiration, sings their school’s alma mater. The losing team’s alma mater is sung first. The losing team’s players face their fellow students, and the winning team stands respectfully behind.

Then the players of both teams cross the playing field to where the entire student body of the winning team is seated. The winning team’s alma mater is sung, and the losing team’s players stand respectfully behind.

While this may be the greatest rivalry in sports, part of what makes it so special is that once the players leave the field of competition they do so with the knowledge that they are brothers and sisters in arms. Duty, honor, country.

Win first; sing second.

In most of the rest of the world being second can be reworded as being the first loser. Being the second person or organization to do something is never good, especially in business.

This will prove to be true with healthcare, with patient access, engagement, and experience. Suppose the competitor to your health system reinvented patient access, engagement, and experience? Suppose they made it easier for people to do business with them, and they did it by creating a remarkable online interactive experience?

Using their system’s customer and patient portals, people could access that health system. And that health system could access people; patient people and consumer people—two-way access. People could store and manage their health data, daily data about their health. People could easily conduct all of their business with that health system without ever having to call someone.

It would be like doing business with any other large innovative company.

If your health system becomes the second health system in your area to offer this type of user experience you have already lost.

Why? Think about your bank. Think about all the work it took to set up your accounts, all of the work it took to set up all of your online banking transactions. Once you have set up your online services with your bank, how likely are you to change banks?

Not very. If a competitor to your bank offers a free toaster you will not change banks. Why? Because you are all settled in; you are comfortable. Banks have figured out how to lock in their customers, how to retain their customers. And they did it by making it easy for people to do business with them. I have not walked into a bank in more than a decade because there is no need to.

The first health system in your market to make it easy, really easy to do business will win. They will win because once customers have all of their data locked into that system they will not be so keen to move it. Patient retention.

So, here are your choices if you are a health system; choose to sing second, or buy a boat load of toasters and hope you have better luck with them than the banks had.

Improving Access: What Is Your Best First Step?

One of the problems with getting across a new idea is presenting it in a manner that allows others to visualize something they have not seen before.

I think people have that problem when it comes to understanding how to recast patient experience and patient access. We have patients, they think to themselves, therefore those people must have access or they would not be our patients. It is this kind of thinking that allows them to check the box—problem solved, now let’s move on.

So let’s ask the question; exactly what kind of access do people have? Do they have good access? Do they have a good experience when they try to access our health system? Can they accomplish what they set out to accomplish in one attempt? Did they have to talk to more than one person to have their needs met? Was there an easier way for them to do what they needed to do?

Perhaps we can define a few things.

Access: Everyone can interact with the entire organization in a manner that was designed by the organization to provide a good user experience for every type of interaction–not just scheduling.

Ease of Access: People are not willing to work hard to access the health system. Access should be intuitive.

Effective Access: People are able to accomplish what they set out to accomplish 100% of the time.

To learn if your health system has access, or merely has a group of phone numbers for people to call to try to accomplish tasks requires work. You have to look around, and you have to ask questions.

It also helps to have an example of what good access and experience look like. UBER is an example of a company that designed access, designed access to be easy and intuitive, and designed it in a way to be effective. If you have not used UBER, you can see how user-centered-design reinvented the task of getting a taxi by watching this YouTube video: https://www.youtube.com/watch?v=U9A86Nh75xQ

For non-UBER users, the idea of hailing a taxi evokes memories of standing in the rain on a crowded street and competing with others for the attention of the cab headed your way.

For UBER users it works like this:

  • Activate the UBER app on your phone
  • A map comes up on your screen that shows where you are
  • On the map are images of moving vehicles—UBER cars—in your area
  • You enter where you want to go
  • The screen shows you a photo of your UBER driver, a description of the driver’s car and the car’s license plate, and an estimate of how many minutes it will take for the drive to arrive at your location.

Your work is done. When you arrive at your location you exit the car. You do not need to ask for a receipt, it is already being emailed to you. You will then be asked to rate the driver by clicking on how many stars you award. Every driver gets rated on every trip, and the driver rates every rider. If a driver’s average rating gets below 4.2 stars out of a total of 5, the driver will be removed from UBER.

That is the brilliance of UBER. They took a highly dysfunctional industry and turned it on its ear, and the only thing they require of their customers is to enter the address of their destination.

Very slick, and very effective and efficient. A great user experience. In fact, it provides a remarkable experience every time, and the reason the user experience is great each time is that it was designed to be great. Great design, user-centered design, is difficult work.

Design is a verb. In health systems, access and experience were never designed; they simply evolved. Having phone numbers for people to call did not involve design. Having a place where lots of people sit and answer calls did not involve design. Having a website that only allows people to read about the hospital never involved designing the user experience.

Access to most health systems by phone involves a poor user experience. Having said all of that, what is the first thing that a health system should do to dramatically improve the access experience? Since access, using the definition from above, involves everyone, not just surgical patients, not just acute patients, and not just scheduling done by phone, it is important to determine just how poor of an access experience your health system offers by phone.

That said, the first step for improving the access experience is for health systems to determine is to determine how broken the phone experience is, and then design an experience that provides a remarkable experience every time for every caller.

Simply having happy and smiling people answering the phones does not mean the access experience is good. They can smile all day long, but if people have to call multiple times, and/or have to speak to several people, and are still not getting their needs met, their experience is poor.

Sooner or later poor user access will result in people buying their healthcare from another provider.

Should You Improve Patient Experience Scores or Patient Experience?

The woman in front of me at the checkout line in the grocery store had two full shopping carts piled to the rim with food.  She began placing her items on the belt, one item at a time, sorting them into neat categories; perishables, organic, canned goods.  I tried using my ventriloquism, repeating the phrase “get out of the line…get out of the line.”  I could see her looking around trying to place the voice, but she remained fixated on her sorting…place the frozen Salisbury steak next to the TV dinners.

I felt a bead of cold sweat start to wind its way down between my shoulder blades, and a slight shiver overtook me. I started to picture her in front of me at a salad bar, inspecting individual chickpeas prior to placing them on her plate.  The only other thing that could have made the situation more untenable is if the grocer decided to play Celine Dion’s Christmas CD over the loud speakers.

After about twenty minutes the last of her items had been scanned, and the clerk announced the amount. The woman fumbled about in her purse, pulled out a large white envelope, and withdrew a fistful of coupons.  The voice in my head whispered to me “I thought we agreed there would be no killing this time.”  Ten more long minutes passed.

The store manager and I simultaneously saw her reach back into her purse.  Even before we saw it, we both knew she was reaching for her checkbook.  The manager knew he only had a couple of seconds to try to stop the bedlam that was about to explode.  He leapt the service counter, pushed aside the boy bagging the groceries and flung me to the floor.  A Good Samaritan in the next aisle straddled my legs while the manager hooked me up to an IV of Benadryl, and shielded my view from the woman.

That was my day.

If experience teaches us anything it teaches that if we represented the people who think they understand business strategy and planning on a Venn diagram, and also represented the people who actually understand business strategy and planning on the same diagram, the number of those who actually understand it would be like comparing the circumference of the donut hole to the circumference of the donut.

About one hospital in seven has a defined patient experience strategy, and of those that do almost all of those strategies focus exclusively on what occurs within the hospital, and almost all of them rely exclusively on improving HCAHP scores.

That said, we can make a few observations about why it is difficult for any hospital to make any significant improvements regarding patient experience:

  • 85% of hospitals do not have a system-wide patient experience strategy even though ninety percent of hospital executives rank improving patient experience as their first or second priority over the next three to five years.
  • Of the fifteen percent with a strategy the vast majority of those strategies are constrained by what occurs to the patient in the hospital.
  • Most hospitals do not measure the experiences or levels of satisfaction of their outpatients.
  • It is possible that no hospitals measure the experiences or levels of satisfaction of prospective patients.

Should providers be improving HCAHP scores or improving patient experience? While it may seem like splitting hairs, the two efforts are no the same. Should we be trying to improve patient experience, or should we be trying to improve patient experience scores? I think you can improve the scores without improving the experience, but you cannot improve the experience without having it raise the scores.

What is the health system’s definition of improvement?  Where is the plan?  For most systems the goal is to raise their score. Move the number from A to B. But then what? Where is the strategy? What is the retention goal?  The referral goal?

Not a single patient or consumer in the country can tell you the HCAHPS score of their health system. I bet none of Press Ganey’s employees knows the score of their provider.

And what is the unicorn in the patient experience waiting room, what is the question nobody is asking? It is this—why are providers trying to improve their scores? Other than not being penalized, how does the provider benefit from having a higher score?

Alternatively, how would a provider benefit by actually improving patient experience? Actually improving patient experience, patient access and patient engagement results in:

  • Higher patient retention
  • Higher patient referrals
  • Improved revenue cycle
  • Lower customer service costs
  • Reduced admissions and readmissions

Now that seems to be a strategy that if I were the CEO or CFO or COO or CNO that I could get my arms around.

What Can You Learn About Patient Experience From USAIR?

It is snowing. Flight home cancelled.  My hotel room was cancelled, cancelled while I was still in it..

This is also happening for newly-minted MBAs.  Blizzard; no worries.  Smart phone, new reservations, care to join me for drinks?

I wonder how they would handle it the way we real men had to handle it in the days before Al Gore invented the internet.  Would they even know where to begin?

In the old days, when mastodons still roamed downtown Boston, a good snow storm meant you might not get home until the lawn needed mowing.  They way this mastodon remembers it, everyone in the cities affected by the storm would call the one phone number for the airline to see about rescheduling their flights.

If you could not extend your stay at your hotel, you were basically out of luck.  There was no way to Google the hotels in your zip code, there was no way to even know which hotels to call.  You would simply dial ‘411’ and start asking an operator to connect you with a hotel other than the one at which you are currently registered.

When that did not work, and after the bellman at your hotel tossed you onto the street, you would make your way to a copse of trees, hope you remembered your Navy SEALs training, and try to build a bivouac with your comb and toothbrush under the branches of a juniper bush.  As the snow fell in earnest you might fashion a pair mukluks from yesterday’s socks.  If you were really fortunate, you might still have a piece of adipose tissue—seal blubber—saved from the last time you were forced to play survivor.  That is how real men did it in the old days, in the days before the entire world started to function around the internet and mobile phones.

Segue.  Hospitals.  Was that a mastodon I saw in your lobby?  I just bumped into someone from IT and she dropped her computer punch-cards—you younger ones may have to Google the term.  In the last five years smart phones and the internet have changed how Americans conduct business; how we buy goods and services.

They have not, however changed how we interact with hospitals.  For those who still have phone books if you look up your hospital in the phone book you will see dozens of numbers to call.

Riddle me this Batman; which of those numbers are you supposed to call if you need to schedule a lab?  It depends.  Which number should you call for a refill?  It depends. For a follow up appointment?  And so forth and so on.

As a prelude to the snow while I slept last night, using the internet, US Airways did all of the following—cancelled my flight, messaged me to let me know the flight was cancelled, rebooked me on a flight, and sent me a message confirming my new seat.  In real-time, all while I slept.

Most hospitals cannot even schedule the original appointment using a phone, let alone reschedule it and send me a confirmation over the internet.  The mastodon model of patient access works as follows.  I call the hospital, am placed on hold, am asked for my referral, my authorization, my insurance.  Then I am transferred to someone else, am placed on hold, am asked for my referral, my authorization, my insurance.  I may get an appointment, I may not.

While I am on hold with the hospital I rebook my hotel, watch a movie on HULU, search eBay for a mastodon tusk, and show my dog a video to teach him how to shut the door.

I’m thinking this whole internet/smart-phone thing may have legs.

As a hospital, are you really comfortable offering less of a customer experience than an airline?

A Thought For Thanksgiving

May I take you on a tour of my home?  You enter through the front door.  On one side is the living room, on the other sits the dining room.

The living room looks exactly like it did the day the movers dropped off the furniture.  It might as well be cordoned off with red velvet rope and polished brass stanchions.  It reminds me of taking the tour of Independence Hall, seeing the quill pen right where Mr. Hancock left it.  Nothing has been disturbed over the years.

We don’t use our living room.  We vacuum and dust it, just like everyone does.  We didn’t use it when I was young either; I’m starting to think it might make a good spot for a hot tub.

Opposite the living room is the dining room.  If your family is like mine, when the dining room isn’t being used for folding laundry, building jigsaw puzzles, or preparing taxes, it is used for high holidays, proms, weddings and funerals.

We have a set of china I bought from England on eBay.  We’ve probably used it a half dozen times.  It’s for special occasions—like the passage of the healthcare reform bill.

Twelve years ago this Thanksgiving I was sitting on the floor of our dining room, inspecting the dishes and silverware when I came upon an unopened box of off-white tapered candles that was tucked away under the starched cotton linens.

It gave me pause.  The receipt was taped to the candle box—purchased five years ago.  Why?  In case we needed them.  In case there was an occasion so special as to warrant candles. At the rate we were using them, our candles and china would have lasted for hundreds of years.

I got to thinking, what occasions warrant the lighting of candles? 

I almost never had the chance to learn what occasions would cause me to light our candles.  Less than two weeks after that Thanksgiving, while watching an episode of the Sopranos, I was having difficulty breathing, a lot of difficulty.  I stepped outside to have a cigarette, and to sort out why I could not breath. Collapsing to the floor convinced me that I was having a heart attack.

Less we be distracted, this post is about the candles, not the heart attack.

I remember thinking, as I lay strapped to a gurney in the back of the ambulance, about those darned, unused candles.

A lot of people are saving their candles for more important occasions.

No occasion will ever be any more important than the occasion of simply having tomorrow.  These days we burn the candles, stain the linens, and break the crystal and the china. Let’s agree to light a lot of candles this year.

Warm regards, Paul

Patient Experience: What Exactly Needs to Change?

Please be on the lookout for my one-man production, Paul Sings Les Misérables. Those of you who have been on a recent train or plane with me may have heard me practicing.

There are around 4,100,000 hotel rooms in the US. People who study obscure facts recommend pillows be replaced every two months. If we assume that each hotel room has four pillows, the hospitality industry should replace about a hundred million pillows a year. I travel a fair amount, and I have yet to see a pile of discarded pillows at any hotel

It occurred to me that if one measured healthcare’s attempts to improve patient experience and patient access in dog years, we might understand that the expiration date of those efforts have come and gone.

And so I wondered, how might we alter our efforts in order to get a better result?

Health systems, for the most part, have created a generic persona of this entity we call a patient. In almost all of those personas, the persona’s attributes are limited to those of inpatients. In other words, not only are the attributes not tied to any specific individual, they exclude most of a health system’s stakeholders.

And as much as we would like to believe that access and experience have improved, if we look at how hard people have to work to interact with a provider, most of it still happens by phone. The only innovation in patient access over the last fifty years does not come from health systems, it comes from the companies that make the phones—rotary phones to touch tone phones to mobile phones.

Even with all of that innovation, the people who call are still subjected to having to wait to talk with someone, and to having to speak with someone who cannot meet their needs. It is the same old problem, only now we have cooler devices.

Let’s spend a minute looking at whether there is merit in unbundling the attributes we associate with a patient or consumer. Let’s start with a sample group of a million people. We naturally segment people into groups; for example, dog people and cat people. Suppose in a sample of a million people, six hundred thousand of them are dog people.

Of those six hundred thousand, suppose seventy percent are coffee drinkers and thirty percent prefer tea. That gives us four hundred and twenty thousand people who like dogs and drink coffee. Of that group, half favor football and half favor baseball; two hundred and ten thousand dog-loving, coffee-drinking football fans. And of those who like dogs, drink coffee, and favor football, ten percent are fans of the Dallas Cowboys; 21,000. Five percent of those people live in Seattle, and of them, twenty percent hate the fact that rains often in Seattle—that gets us to a group of 420. Of the 420 dog loving, coffee drinking, football loving, Cowboy fans who live in Seattle and that hate the rain, thirty percent of which refuse to carry an umbrella—123 people. Seventeen of the 123 have red hair, nine of the seventeen are married, three of the nine do not have children, and one of the three is a republican.

Sooner or later segmentation comes down to the preferences of one person.

What if the sample was population one million people who at some point have been patients, and all of who will be patients again? They do not fit easily into a homogenous group. Some of those individuals are patients, some were patients, and some will be patients. Some battle chronic diseases. Some have children. And some, for reasons understood only to them are Dallas Cowboy fans.

They have their own experiences, and they have their own expectations of what those experiences should be. To be blunt, an individual does not care about how great everyone else’s experience were. A person cares about how great their experience will be.  Their is not a patient or a consumer in the US who can tell you the HCHAPS score of their provider.

Healthcare is not eCare, heCare, or sheCare.  It is meCare.

Measuring patient experience using just HCAHPS assumes homogeneity. That approach relies on the fact that creating a homogeneous experience will keep everyone happy. Try that same approach on a married and childless, wet Dallas Cowboy fan and his dog that live in Seattle, and who voted for Mitt Romney in the last election.

Improving patient access and experience requires making it feel like it was designed to meet the needs of each individual. And since the only thing that seems to change is the type of phone being used, if you want to really improve access and experience, get rid of the phones and let people interact with your health system online.