Why Is Patient Experience Like A Peach Basket?

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

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 Experience.  What is the best way to respond 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 experience 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 experience scores does not mean that your patients are satisfied with your hospital. All it means is that you scored high on the CMS survey.  Nobody ever asked patients and consumers what factors determine their satisfaction.

To the chagrin of the ‘six sigmaists’, here is a news flash.  Shaving twenty-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–make it easy for your patients

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–sixty percent of people go to an organization’s website before they call the organization.  You want to pull out your iPad, go to the provider’s customer portal, upload a copy of your insurance card, complete the forms, and be given a QR code.

Patient satisfaction just went up. Patient experience is not the same thing as patient satisfaction.  Everyone has an experience. Many of those experiences are not satisfactory.

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

Why Do People Work Hard To Make Customer Experience Poor?

I went to the fifties-looking diner at the airport, sat at the worn Formica counter, and ordered toast.

The waitress—I did not opt for the politically correct waitperson because the person with whom I was about to converse was in fact a she—rocked back and forth on her rubber-soled shoes. “Do you see toast on the menu?” She asks.

I scanned the laminated and crusted placemat cum menu. “I do not. But the toaster is right there,” I said as I pointed to the spot on the laminated counter next to the display case holding the lemon meringue pie and some kind of turnover that looked like it had last been turned over days ago.

“The toaster is for the toasted tuna sandwich,” and she pointed to the menu. And there it was. About a half-inch to the right from what looked to be a yolk smear, and an inch or so down from what appeared to my untrained culinary eyes to be a glob of jelly. The glob appeared to be strawberry jelly, but it could just as easily have been congealed ketchup.

Jelly. Next to the bowl of creamers and the small box of sweeteners was a woven wired device with rows of jelly stacked like Legos. “Why is there jelly if you do not serve toast?” She looked around like she was wondering if she should call her manager.  I heard her misquote under her breath a line from Shakespeare’s Romeo and Juliet, “A pox upon your house.”

By now I no longer wanted the toast, but I could not convince myself to just step away from the counter and admit defeat. I read the menu’s chipper narrative about the sandwich. Whole white albacore tuna, harvested in dolphin-free waters. Served on your choice of fresh bread, lightly toasted—there was the word I sought. The tuna sandwich came with lettuce and cheese and tomato. And tuna.

And toast. “May I have it without the cheese?” I asked—raise your hand if you think you know where this is headed. She nodded affirmatively.

“You know what? Now that I am thinking about it, let’s skip the lettuce and the tomato.”

“What will you have to drink?” I ordered a Diet Coke.

And as she began to turn to take my order to the kitchen I made a final request. “And hold the tuna.”

Toast. Customer experience.

It was the worst of times; it was the worst of times. It was never and never will be the best of times if you fly USAIR or American. My trip to the dark side of customer service was via American Airlines, on a flight I booked on USAIR, on a plane flown by Republic Airlines. That way, I would have to work hard to know which airline to blame for my bad experience. It seemed the airline troika had secreted away the culpable party like nested Russian dolls, or in much the same way John le Carré would launder clandestine funds through a series of Swiss banks and offshore accounts.

Having finished my tuna sandwich, sans tuna, I arrive at the airline terminal in time to catch an earlier flight; fifteen minutes before they shut the door. “May I get on this flight?” I inquire of the gate guardian.

“It will cost you seventy-dollars,” she tells me.

Still amped from my toast experience, I say, “Think about it this way. You have empty seats, seats you will not sell because there is not time left. It costs you nothing to put my backside in one of those seats. And in doing so,” as I build to the climax of my logical argument, “You then free up a seat for the next flight, an unpaid seat that you might sell.”

I give her my second-best smile. “Do you want to get on this flight?” She asked me without giving me her second-best smile.

I looked at my watch. There were two hours before the next flight, and I was still hungry. “No thank you. I think I’ll go get a tuna sandwich,” I told her.

Patient Access: Why Are 60% Of Your Patients Already Disappointed?

What would you do differently if you knew that sixty percent of the people who are calling your health system were already disappointed by your health system?

Would everyone have better experience if the health system closed its call center? Quite possibly. Why run the risk of disappointing the other forty percent of your callers for the first time, and disappointing the other sixty percent for the second time?

And how could we have already disappointed sixty percent of the callers if this is the first time they are calling us?

A fair question. An important question; one with an answer steeped in fact.

National call center data shows that sixty percent of an institution’s customers will go to the institution’s website to solve their problem before giving in and calling the institution. That same data shows people do not want to call a company because their expectation is that the experience will be poor.

So, for those call center managers who are using willow witching techniques report how high their first call resolution is, whatever numbers you are reporting are way too high.

First call resolution has already come and gone. Sixty percent of your callers have already had at least one failed attempt to access your health system. They went to your website and could not find what they needed to find.

So, what do we know?

  • We know people expect a bad experience if they call so they go to the website
  • People get a bad experience on the website—a bad experience is defined as wanting to accomplish something and being unable to do so
  • Because they could not get their needs met online they call the contact center
  • They will not return to the website the next time they need something because they know their needs will not be met
  • Many of their expectations of having a bad experience when they call are met
  • This makes it even less likely that they will call the next time they need something

Poor access online. Poor access on the phone.

Many, if not most health systems provide a user access experience that is less satisfying that the experience patients get when they call their payer to file a dispute.

User experience equals access experience. User experience equals patient experience. How good is your health system’s user experience?

See what you can accomplish online. See how easy it is to accomplish anything on the phone. Unless you come away saying, “Wow, that was easy,” your health system has a lot of work to do.

Patient Experience: What is Wrong with Pushing the Envelope?

Fifteen years ago, my consulting client was the public telephone provider of a large European country. The country had just offered competitive telephony licenses to the private sector. My project was to develop a customer experience strategy for the incumbent that would help the public phone company retain customers.

My team and I spent months visiting the various call centers throughout the country, and we visited several of their satellite phone companies in South America—sort of gives you a hint as to which country’s phone company was my client.

The most astonishing thing I learned was that the phone company had nine thousand people in the call centers—CRSs; call center representatives. Actually, as it turned out, it was the second most astonishing thing I learned. The most astonishing I learned was what happened when someone called the phone company.

Think back to the days when we had phone companies in the US. Back to when you could dial zero and speak with an operator, or dial 411 and get directory assistance. Back when your phone bill was thirty pages long. Imagine calling AT&T or USWEST, asking a question, and having your call transferred to someone who may be able to answer it. Imagine that for millions of calls a year.

That was the customer experience of my European client. They had 9,000 CRSs; nine thousand people whose job it was to take the customers’ calls. Yet unlike when you call a company today in the US with a question, when you expect the person to whom you are speaking to answer your question, that was not how it worked with my client.

The job of these 9,000 people was to listen to a caller’s question, and then determine which person or persons in the phone company should answer that question. They would write down the caller’s information and then they would give the caller the phone number of the department the caller should call to get their question answered—for example, billing—and then the CSR would hang up. The CSR would then fax the caller’s information to the appropriate department. That alone resulted in over ten million faxes a year.

Everyone has called a company and had to listen to a recording that resembled something like, “To schedule and appointment press 1, to ask a question about your bill press 2….” The technology providing the recording is called an IVR, an Interactive Voice Response System.

My European client employed a manual IVR; no system, just 9,000 people routing calls, routing calls at a fully loaded cost of about thirty dollars a call. They spent more than a billion dollars a year having people tell callers which department to call. A very expensive manual version of an IVR. They also spent untold hundreds of millions of dollars a year sending faxes, and handling repeat calls.

I presented my findings to their executives along with a vision of what they could be doing to improve customer experience. The company’s CIO—which could be an acronym for Career Is Over—walked to the white board and erased my vision. When I asked why he had done so he told me my vision was too theoretical, that it did not exist anywhere. In response, I walked to where he was seated, picked up his day timer—younger readers may need to Google the term—and told him to give me some dates that he could travel to the US and visit any number of US companies who knew how to manage customer calls.

That was fifteen years ago. At that time, I could not have invited him to visit a health system because there was nothing of value to show him about how to improve his call center.

So, has anything changed in healthcare regarding the effectiveness of customer experience in the last fifteen years?

It has not. And the facts back it up.

Whether your health system gets a hundred thousand calls a year or a million calls a year, I am eighty-seven-point-five percent convinced that your health system does not have a call center or a contact center.

I’m pretty certain, as are you, that your health system probably has a bunch of people in a large room, and in that room are a lot of phones. And that is about as far as designing the telephone customer experience strategy goes.

The phone rings.

Someone answers the call.

Then what happens? Seventy to eighty percent of those calls are transferred by your health systems CRSs to someone else in the health system in the hope that whomever the call is transferred to can answer the call.

Did someone else answer the caller’s question? Nobody knows. Did the caller have to call more than once about the same issue? Nobody knows. Did the caller wind up going to ED because the person wanted to speak with a nurse and there were no nurses to speak with? Many did. Were the caller’s needs met? Who knows?

Did you know that seventy-three percent of the times when someone may wish to call their health system there is nobody around to answer the phone? Not everyone gets sick only Monday through Friday between 8 A.M. and 5 P.M. Not everyone finds it convenient to call only Monday through Friday between 8 A.M. and 5 P.M. because, like you, they are working.  Patient experience has nothing to do with being available to answer the phone during the times you want people to call you. It has everything to do with being available when they want to call you.  Some health systems may think they provide 24 hour customer service; 8 hours each on Monday, Wednesday and Friday.

Tonight, if you find yourself awake at some odd hour, call your cable company. Somebody will answer the phone. If you do not want to call them, go to their website you can get your needs met online as well.

So, how can health systems dramatically improve patient access and reinvent patient experience? They can start by designing a call center, not just a scheduling center. They can design the access experience to enable patients to get their needs met with a single call, speaking only to a single person. The health system could also expand the hours of its call center.

Some people think doing so is pushing the envelope. I think doing these things is the bare minimum requirement. If you want to think out of the box, do not think about pushing the envelope, think about bulldozing the envelope. Design an online, interactive customer portal that can meet the same needs that a fully functional call center should meet.

Patient Experience: What A Veteran Taught Me

Some days, the best thing you can do is to be present. Last week I had such a day. I arrived for my meeting with the director of a large VA facility. The taxi dropped me several buildings away from my meeting, so I created my own way-finding path through the hospital.

During my ten-minute walk I passed dozens of unknown heroes. Veterans of all ages, colors, and backgrounds. As I made my way down an almost vacant polished hall, I was confronted by a man’s raspy voice.

“Where are you going young man?”

The gentleman had my attention just by referring to me as young. He was seated in a wheelchair that was parked next to the wall. To set the scene, he is African-American—in know the English majors will write me saying that I just messed with a past present participle about something having to do with the tense I used, but he was, and thankfully he is.

The veteran wore a black baseball-style cap, the embroidery commemorating his service in Korea. A medal was affixed to his worn sweatshirt. Not being an anthropologist, I estimated the gentleman, the gentleman who sought my attention, was in his eighties. (That made me a young man.)

A brief aside. I was vey uncomfortable. I was uncomfortable not because I might be late for my meeting, not for being called out by a stranger, but for feeling inadequate and unworthy to say anything that could be of much value to him.

Nobody had ever shot at me. I have never knowingly spent the night in in a foxhole thousands of miles from my home wondering if I would be alive for breakfast. The gentleman before me probably had. His eyes looked through me as though I was simply a prop in something he had endured long ago.

“I’m Bill,” he told me. We shook hands. His fingers were long and sinuous, and weathered with age. I noticed his yellowed fingernails were neatly manicured. Bill paused, and I attributed his pause to him reflecting over what I assumed to be decades of memories. I was grateful for the pause, because I did not have any idea about what he hoped for in terms of a response from me.

“You look like a school principal,” he told me—suit, briefcase, polished shoes.

Not caring if I would be late for my meeting, I knew the most important, and best part of my day was going to happen in the next few minutes. Bill’s skin hung from his frame like sheets of wrinkled wallpaper that were no longer affixed to the wall. Without any knowledge of the appropriate decorum for how to address the gentleman facing me, the former soldier, I placed my briefcase on the floor, and sat cross-legged on the worn, linoleum tile.

I recall wishing that I had been wearing clothes from the Salvation Army, not because I did not want to dirty my suit, but because I was afraid my clothing might have made me standoffish. Bill was not put off by my attire, and by God’s grace, I sensed he knew his did not put me off.

I wish I understood everything Bill said. I sensed he simply wanted someone to speak with him, and so that is what we did. All he wanted was someone’s ear, and I was lucky to have two ears that were not being used.   We did not trade great insights, we simply shared a few minutes of time. Sometimes, if you are lucky, you can improve someone’s patient experience for free.  Maybe you can even make someone’s day. He sure made mine.

Please know, I was not prompted to write this because of me, this has nothing to do with what a great guy Paul is for spending a few minutes with an elderly veteran.

My only reason for writing today is to share that I will end this day better than I started it. I hope I will be better for having had it, for having participated. I will end it without knowing what this gentleman did to earn my respect and fealty, but I know he did.

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.