Disrupting Patient Experience

So I’m making dinner the other night and I’m reminded of a story I heard a while back on NPR. The narrator and his wife were talking about their 50 year marriage, some of the funny memories they shared which helped keep them together. One of the stories the husband related was about his wife’s meatloaf. Their recipe for meatloaf was one they had learned from his wife’s mother. Over the years they had been served meatloaf at the home of his in-laws on several occasions, and on most of those occasions his wife would help her mom prepare the meatloaf.

She’d mix the ingredients in a large wooden bowl; one pound each of ground beef and ground pork, breadcrumbs, two eggs, some milk, salt, pepper, oregano, and a small can of tomato paste. She’d knead the mixture together, shape into loaves, and place the loaves into the one-and-a-half pound pan, discarding the leftover mixture. She would then pour a mixture of tomato paste and water, along with diced carrots and onions on top of the two loaf, and then garnish it with strips of bacon.

He went on to say that meatloaf night at home was one of his favorite dinners. His wife always prepared the dish exactly as her mother. One day he asked her why she threw away the extra meatloaf instead of cooking it all. She replied that she was simply following her mother’s recipe.  The husband said, “The reason your mom throws away part of the meatloaf is because she doesn’t own a two-pound baking pan. We have a two pound pan. You’ve been throwing it away all of these years and I’ve never known why until now.”

Therein lays the dilemma. We get so used to doing things one way that we forget to question whether there may a better way to do the same thing. Several of you have inquired as to how to incorporate some of the patient experience strategy ideas in your organization, how to get out of the trap of continuing to do something the same way it’s been done, simply because that’s the way things are done. It’s difficult to be the iconoclast, someone who attacks the cherished beliefs of the organization. It is especially difficult without a methodology and an approach. Without a decent methodology, and some experience to shake things up, we’re no better off than a kitchen table amateur (KTA). A KTA, no matter how well-intentioned, won’t be able to affect change. Without them the end results would be no more effective than sacrificing three goats and a chicken.

So, here we discuss how to disrupt patient experience, how to find a champion, and how to put together a plan to enable you to move the focus to developing a proper strategy, one that will be flexible enough to adapt to the changing requirements. But keep the goats and the chicken handy just in case this doesn’t work.

I’m sure you have seen the dance when someone in your organization expresses an idea about how to change something that most people do not think needs changing. It looks a lot like two dogs sniffing around each other to see whose top dog.  People like being on the solid ground that comes with maintaining the status quo, afraid that if they step off they will be on a greased slope, or even worse that they will be sent to the penalty box to listen to old ABBA songs.

A gentleman in my meeting was pointing at something in my presentation with all of the trepidation of a new geography teacher trying to locate Burma on an outdated map. I knew how he felt. Sometimes l like to leave a trail of breadcrumbs for my audience to follow as I try to make my point. 

But we have all had times where we would have been served better had we left a trail of croutons instead of breadcrumbs. (Croutons are larger, making it easier for people to follow them.) Those are the times when you feel it would be easier to slip a hippo through a clarinet than to slide a fresh idea between two synapses, like trying to explain cholesterol to a Big Mac.

So there I was in the meeting laying out my vision for the hospital of the future, one in which patients would carry their hospital around on their iPad the way people carry around Amazon today. One member of the audience asked me if I had ever seen such a hospital. I replied that I had never seen such a thing, but then again I had never seen my pancreas, yet I knew I had one.

There is no technical reason why someone cannot interact with their hospital online to accomplish all of their business needs. There is no technical reason why someone cannot register, schedule, admit, manage their discharge, educate themselves, monitor their health, set up a payment plan, refill a script, or file a claim.

The only thing preventing this is that nobody has stood up and said “Let’s do it.”



The 5 Personas of Patient Experience

Playing a trivia game as an ice-breaker at a networking event, the question was, “A five-letter word for a reptile.”

The woman next to me shouted out, “Spider!”

Foolishly I hoped she wasn’t actually replying to the question, but was responding to the fact that perhaps a Brazilian Wandering Spider—the deadliest spider on the planet—had just entered her alimentary canal.  (I thought I would reference Brazil since we just completed the World Cup.)

As it turned out, there was no spider in her ear, and there was not much between her ears. My IQ dropped several notches. I decided that I had broken enough ice for one day.

I looked at my wife.  She told me she had to call Dallas.

“All of it?” I asked. She rolled her eyes at me. I am a stickler for syntax, for terminology. I think when we use words we should, at a minimum, know the meaning of the words we use.

Let us take a minute to define who and what we are talking about when we use the word patient.

I posit that from the patient’s perspective the word patient has a broader definition than the way the hospital defines it. Hospitals, for the most part, define patient as someone undergoing a billable event. Someone producing revenue in real-time.

I believe there are five patient personas, each of which had a question they need to answer:

  • Prospective patients
  • Outpatients
  • Inpatients
  • Discharged patients
  • Former patients

Prospective patients: Will I buy healthcare from this institution

Outpatients: Involved with the institution—Will I but more healthcare from this institution?

Inpatients: Committed, at least for the moment to the institution. (The chicken is involved with breakfast, the pig is committed.)  Will I buy healthcare again from this institution?

Discharged patients: Will I buy healthcare again from this institution?

Former patients: Will I buy healthcare again from this institution?

The only personas for which the hospital knows the experiences of a particular persona are the inpatients. And what do they know? Do they know your experience if you happen to be the inpatient? Of course not. The only thing they know about the experience of an inpatient are the aggregated experiences as those experiences relate to the HCAHPS scores of a sample of inpatients several months after those people were discharged, a ‘generic inpatient’.

If the personas of a person’s patient life-cycle can be traced from prospective patient, to outpatient, to inpatient, to discharged patient to former patient, the hospital knows almost nothing of those experiences, and they know absolutely nothing of the experiences of you as an individual.

The value of what a hospital knows about the experience data it has collected is the hospital’s ability to try to avoid CMS penalties.

The value of what a hospital does not know about the experiences of the patient personas is substantial.

Why is Patient Experience Like A Chicken Crossing the Road?

Nine miles into my run I was at the apex of the bridge crossing the bay, leaning over the guardrail to catch my breath. To my surprise, a state policeman pulled alongside of me.

“What are you doing?”  He asked, a tone of concern in his voice.

Since I was trying to cross the bridge, I thought about asking him if his question was like why did the chicken cross the road, but he did not look like a chicken crossing the road kind of guy.

“Are you okay? You don’t look okay.”

“I’m fine. Why did you pull over?” I asked.

“We got some calls about a guy on the bridge who looked depressed. Are you thinking of jumping?”

“Jumping what?”

“Jumping off the bridge. Are you sure you are okay? You look depressed.”

“I think I look like I just ran nine miles.” I placed my foot on the guardrail to stretch my hamstring.

“Take your foot off the bridge,” he commanded. “I was about to call for a helicopter. Are you sure you are okay?”

I was going to ask him if the helicopter would give me a ride back to our house in Ocean City, but he didn’t look like a give me a ride back kind of guy. “May I continue across?”

“No, you can’t do that here.”

An interesting statement, You can’t do that here. I was looking at a hospital’s website and there was a link suggesting if I clicked it I would be able to schedule an appointment.

I clicked it. The next page told me how good the hospital was. The page after that told me about all of the services they provided. The last page told me that if I wanted to schedule an appointment that I should call the hospital Monday through Friday between eight AM and five PM.

The website’s page should have included 24-point bold disclaimer stating, You can’t do that here.

Sort of like when I was trying to cross the bridge.

Most hospital websites should offer that disclaimer, You Can’t Do That Here. On most hospital websites people cannot do anything except read about the hospital. People are looking for an easy way to do business with their hospital, a way that has a great user experience.

Maybe you should turn your hospital’s website from a brochure into a business tool.

Pale Rhino Logo

What are the patient experiences of the unsurveyed?

Does the fact that there are so many different definitions of patient experience among hospitals belie that fact that there is no definition of patient experience? 

Most patient experience definitions seem to be missing a few things; they do not exist much beyond the four walls of the hospital—sort of like EHR, they are highly, if not exclusively, focused on things having to do with HCAHPs.

(If you want a downloadable presentation on the questions not covered by HCAHPS, you can get it at: The Experiences HCAHPS Doesn’t Survey)

Every day many more patients and prospective patients interact with the hospital using the internet and their phones. Much determination on patient satisfaction, by patients, is made using these tools. Retention, referrals, and ‘win-backs’ are influenced here. “Buying” decisions are made and lost here.  The hospital either met or did not meet expectations.

Yet most hospitals invest almost nothing in the two areas that have the highest number of touchpoints.

If I were asked to define a goal for patient experience I would recommends “A remarkable experience for every patient every time, obtainable on any device, at any time, at any facility.”

To move towards the goal of being remarkable, one must talk to patients and observe them in those touchpoints that all patients use. Surveying patients puts out the fire, it does not prevent fires.  Their bad experience has already happened. 

Surveying patients, paying for patient experience data, and paying for coaching does nothing of value for most of the people in the hospital’s radius of influence. It does nothing for all of the prospective patients and nothing for former patients whose next visit to the hospital is never recorded because that patient went somewhere else.

The level of satisfaction for these individuals is determined outside of the hospital’s four walls.  Writing a million dollar check to have a firm coach your employees does nothing.  There are gobs of people—a consulting term of art—who never become patients or never become patients again. These people make their decisions based on their online experiences with the hospital and on how their calls to the hospital are handled.  HCAHP surveys will not entice them to become your patients.

There is not a patient in the country who can tell you the HCAHPS score of any given hospital.

These people whose experiences are unknown belong to a group called the unsurveyable.   They also represent a healthcare spend higher than the hospital’s total revenues for last year.  Why not pay attention to their experience?


The Half-Life of Patient Experience

My twelve-year-old son commented as I was ready to depart for my run. “Are you really going to wear those shorts?”

“What is wrong with my shorts?” I asked.

“People want to see a lot less leg and a lot more shorts,” he replied.

“How long do my shorts need to be?” I asked. He pointed to a spot between my knees and ankles—capri-length.

If I wore something of that length in red or blue in most major cities in the US I might be mistaken for a gang-banger. Except for the briefcase, the ultra-notebook, and my tan Allen Edmonds wingtips.

That is what got me thinking about forming a management consulting gang, marauding through C-suites wearing white, highly-starched, Egyptian-cotton, below the knee shorts with the Allen Edmonds wingtips—hair gel and manicures are optional.

You probably know that the half-life of something is the time required for a quantity to fall to half of its measured value from what it was at the beginning of the time period.  Its most commonly used with exponential decay, like measuring the age of rocks based on the decay period of radium to lead-206.

The satisfaction with one’s patient experience is the inverse of half-life.  The level of satisfaction of the experience does not diminish over time, it actually grows, and with social media it grows unbounded, at least the bad experiences do—sort of like telling your friend how large the fish was you caught; over time the size of the fish gets bigger.  A story of an unsatisfactory or a bad patient experience has legs, and patients who had a poor experience do their utmost to get their story to the most readers.

A friend of mine who reads this blog called me to relay her story. She is being treated for cancer at a major institution in Baltimore—I’ll leave it to you to figure out which hospital.  She tried to make an appointment to see her doctor because of the side-effects from her anti-nausea medicines.  She said she spent three hours on the phone trying to schedule the appointment.  While she acknowledged that the hospital was the best place for her to be treated she stated that she was going to make it her mission in life to tell people not to go to that hospital simply because they could not handle a simple business process like scheduling an appointment.

Think about the most inane stories someone ever told you.  People, guy people in particular, have a tendency to exaggerate and to add a flourishes that grow over time.  The bad news for healthcare providers is that once patients’ stories hit the web they multiply.

If you want to know how others view your hospital, much more information can be learned from Google than from CMS.  And the opinions on Google, whether accurate or exaggerated have no half-life, that genie is not going back in the bottle.

Hence, the only influence you have over someone’s experience is while they are having the experience.  Once they’ve had it your chance to manage it is over.  And the thing that should concern hospital executives the most is that they do not even know that people are having these bad experiences.

These experiences are not learned from a Ouija-board secret-shopper exercise.

Ninety-percent of the experiences people have regarding their interactions with a hospital are unknown to the hospital, unmeasured by the hospital, and unreported. Companies like Amazon track the successfulness of each interaction of each person.



Patient Access–It’s time to trade in your Palm Pilot

I watched the movie Jaws recently. It was made in 1975. In 1975 I looked like the keyboard player for the Moody Blues (see photo). I wonder how different the movie Jaws would be if someone tried to make it today using today’s technology.

Bathers would see the shark’s fin. Using Bluetooth, they would triangulate on the fin, send a GPS signal to any CIA drone not targeted on some Middle-East Sadam-wanna-be. The drone would shoot a Hellfire missile into the surf on Amity Island, and the tourists would be dining on sushi.  Game over. Movie over. Pass the wasabi and pickled ginger.

When Jaws was filmed in 1975—where is Richard Nixon when you need him—if any of the visitors to Amity Island fell ill, there was no way for them to go to the Amity Island Hospital’s website to check their symptoms. No way for them to schedule an appointment online. No way for them to request a refill online. No way to seek a second opinion online. No way to call from the beach to talk to a nurse.

Technology is great, unless you have spent the last forty years without it, or you are looking to upgrade to a newer version of your Palm Pilot. In the movie Father of the Bride the wedding planner Franc (Martin Short) responds to Steve Martin saying “Welcome to the 90’s Mr. Banks.”  Sometimes it seems like the business of healthcare, how healthcare is run, has yet to be introduced to the nineties.

Thirty-nine years have passed since Jaws was released. If you happen to be one who studies the business of healthcare it would appear that not much has changed except for the fact that hospital administrators no longer wear bellbottoms, platform shoes, and puka-shell necklaces, and they no longer sport moustaches and long sideburns and long hair.

Accessing a healthcare institution remains the way it was in 1975.  For the most part it cannot be accessed it online. You can barely access it by phone. You still are not a customer or a potential customer.

Many hospitals still believe they have patients, not customers. Unless they change that perception the time will come when they have neither.

There are two ways of looking at access; access to the organization and access to healthcare. 

Healthcare is very impressive. At a recent meeting of the Cardiovascular Leadership Institute Leadership Council of Penn Medicine we watched of video of the transformation of a skin cell into a heart muscle cell—it began to beat!  We can treat numerous cancers and can transplant a face.

We can do everything except schedule an appointment. It may be time to trade in the Palm Pilot.

HCAHPS: A Nail Looking For A Hammer

US soccer fans are a lot like locusts. However, instead of surfacing every seventeen years, we surface every four. Once we are out of the Cup, we are really OUT. Four years ago we will once again try to understand the relevancy of the “offside” rule, and wonder why FIFA does not increase the size of the net and use more than one ball at a time. To badly paraphrase Shakespeare, “We are now in the summer of our discontent,”—the doldrums of professional sports. Pro hoops and hockey, which most people do not equate with sports worth watching have concluded their seven month playoff run, baseball’s 162 games are hitting their midpoint, and football is just a dream on the horizon.

Maybe now American’s can get back to some of the other global sports televised on ESPN channels 31-57, like darts and lumberjacking.

Have you ever wondered why hardware stores sell drills? The next time you are at Home Depot, tell the clerk you need a two-inch hole, and ask the clerk to direct you to the aisle that sells the holes. Stores sell drills because they do not sell holes.
In keeping with the hardware theme, in my workshop I reached for one of my hammers. Have you noticed that hammers survived evolution intact? The one reason hammers haven’t changed is simple—nails have not changed. Long handle, heavy piece of metal at one end. All you need, and nothing you don’t.

The collective noun ‘patient experience’, as viewed by most of the healthcare industry, is no more evolved than a hammer. Thirty-two questions seeking thirty-two answers.
However, patient experience is made up of the individual experiences of thousands of individuals—small things. Small things, which when combined become one very big thing. HCAHPS is the repository by which hospitals have tried to herd the collective experiences of the people in their service area. The problem is that people are no easier to herd than cats.

For HCAHPS answers to be of any use they require the gift of hindsight. It would be better if hindsight was available ahead of time.

Hospitals have a tendency to treat HCAHPS scores like pieces of a large patient experience jigsaw puzzle. Unfortunately, nobody has seen the picture on the front of the puzzle box. Assuming patient experience can be improved just by trying to increase HCAHPS scores makes the solution seem artificially easy, like hoping the nail you are about to hammer isn’t a screw. HCAHPS has a finite number of questions, and a finite number of things to be fixed. But in truth, fixing the problem with patient experience is more like counting votes in Florida.