Improving Patient Access: Are You Smarter Then A 5th Grader?

Next February it will have been forty years since two of my friends and I ran the Kennedy 50-mile hike-run across an ice-covered and boulder-strewn Appalachian Trail, and along the C&O Canal into Harper’s Ferry, Maryland. The Appalachian Trail is on the Appalachian Mountains. Mountain trails go up mountains.

I was reminded of the race because of a conversation I had Saturday with an elderly gentleman who was in the process of running in a twenty-four hour relay on a high-school track, an event I also ran forty years ago.

The AARP runner mentioned having completed the Kennedy run this February.  Then and there I decided to locate my two friends, whom I have not seen since high school, and have the three of us run the race.

On October 14, 1947 Chuck Yeager became the first person to break the sound barrier flying the Bell X-1.  Many people thought it could not be done. On February 6, 2016 I will attempt to break the stupidity barrier although I will not be wearing leather wingtips like Robert Kennedy did when he walked the course during the first running of the race.

I mention all of this because knowing I had less than nine months to train for the event, I ran a few sprints Saturday after I had finished my eight-mile run. It was during my third sprint that my right Achilles communicated that it was done sprinting—I looked the stupidity barrier straight in the eye and continued to run.  Bad idea.

Let’s play patient access together.  The question I wanted to be able to answer is:

When do health systems think patient access and patient experience begins?  What I learned is that for them it begins way too late.

With my foot resting on a bag of frozen peas and after taking two Tylenol, I thought it would be interesting to call a few hospitals to see what I needed to do.  I called three hospitals, at which I or I member of my family had been patients.  None of the people I called were able to identify me from my phone number—Comcast can do that.

Remember, it was Saturday.  As far as patients and consumers are concerned, hospitals are closed on weekends to anyone unless they need the services of the Emergency Department. Using the main number on the hospital’s homepage I made four calls to each hospital and asked four different questions:

  • I hurt myself running, what should I do?
  • May I speak with a nurse?
  • My Achilles hurts, do I need to see a doctor.
  • My Achilles hurts; I want to schedule an MRI.

Each call was either transferred or I was told to call another number or to call my doctor.  The two closest answers I received that may have helped me was an offer to transfer me to the outpatient lab, and one gave me the phone number for a podiatrist.

Next, I went to their websites.  None of them offered online chat. One offered a Contact Us box; somebody would respond to my request within forty-eight hours of the next business day (Wednesday).

I then went to everyone’s favorite and tested solution—Google, and I searched “Triage Achilles Pain.”  Lots of good information.  Feel for a bump.  Assess the severity of the pain.  Ice and Tylenol—I could’a been a doctor.  I read about treatments—whatever you do, don’t do any more sprints.

I found the website for a local orthopedist. It is still Saturday.  Something pops on my screen—My name is Cindy, how may I help you?

Access. Access with a good experience.  An Easy Button.  And I didn’t even need to be in the hospital.  Note to health systems—It is possible to for people to need access healthcare prior to having a hospital bed.

I chatted online with Cindy. She triaged me and recommended how to treat it over the weekend.  She told me if the pain got worse let her know Monday.  If it wasn’t better by Wednesday, let her know.

She called me on Monday.

So, let’s quickly return to the 50-mile race and attempt to draw a comparison to the patient access experience.

Health systems treat people as though the only access attempts that matter to their patients are those that happen at mile markers 25-30.  Attempts to access the health system before you are a patient does not matter, and those that happen once you have left the hospital do not matter.

Noticeably absent from a health system’s view of access are consumers.  Since consumers are not yet patients, health systems to not have a plan in place for consumers to access the health system.

People—patients and consumers—need access when they want it.  Not 8 to 5 Monday through Friday.  They want it how they want it; on the phone and online.  And if online, they want to choose what device they want to use for access.

Until they have that, whatever access they may have will not give them an experience that makes them want to be your patient or to remain your patient.

Maybe that is a little steep for a 5th grader, but I am confident you understand it.

Patient Access–WHY: Is Everyone Asking The Wrong Question?

The Lake Wobegone Effect is the natural human tendency to over-estimate one’s abilities; all of the women are strong, all the men are good looking, and all of the children are above average.  In business it used to be referred to as the Peter Principle, being promoted to one’s level of ineptitude, meat in a seat.

The problem begins with what I interpret to be a corollary of the Peter Salinger Syndrome—everything you see on the internet is true.  My management 101 corollary of Pete’s syndrome is—everything we are doing must be right, or we would not be doing it. Innovation meetings serve as in-house think tanks.  Perhaps what we need are a few less think-tanks and a few more do-tanks.

Woodrow Wilson borrowed brains when he needed help.  That is why God created consultants.  There are times when businesses can improve themselves by borrowing brains and recruiting a chief-table-pounder—an ardent champion of a different way to do things.

When it comes to the concept of improving patient access and patient experience the time has come to pound tables.  Having an HCAHPS committee and a big room with a lot of phones in it to schedule appointments is not enough.

In the spate of problems a health system needs to address, fixing the patient access experience should be at the top of everyone’s list.  Step one is admitting the problem exists—my name is Fred, and we have a patient access problem.  This is a problem with enough magnitude that it warrants being a CEO’s attention.

Simon Sinek created the concept of the Golden Circle.  People—think consumers and patients—don’t buy what you do, they buy why you do it.  In healthcare the WHAT is the service, the HOW is the value proposition, and the WHY is the cause.

golden circle

There are two ways of looking at the patient access experience problem, the ways health systems look at it and the way your chief-table-pounder—me—looks at it.  Health systems approach patient access by first addressing WHAT and HOW.  The way health systems look at patient access makes the WHY nothing more than a byproduct of WHAT and HOW.  It makes WHY almost useless.

colden circle 2

What: We need to respond to patient requests

How:  We created a scheduling center—the big room with phones

Why:  Because patients need appointments

Problem solved. What’s next on our agenda?

What if healthcare started by asking WHY do we need to improve patient access:

colden circle 2

Why:   We need to create a delightful experience for patients and consumers to retain and attract them

How:   People do business with companies by phone and online

What:  We created a call center and an interactive customer portal

Everyone can explain WHAT. May people can explain HOW. To improve patient access healthcare must redefine WHY.  The patient is the object of the access service they receive.  They are the subject of the access experience they receive.

Health systems should start by defining WHY improving access is important, and by creating an enterprise-wide patient access experience strategy—remarkable access for every person every time, at any time, and on any device.

rhino services

Is Your Hospital Like This?

I would have been better suited and more comfortable had I been a product of the era of Mad Men.  I see much of life as though I am living it through a black and white television program.  The world seemed to make more sense at a time when we thought we knew how to handle everything.  There were simple answers to even our greatest perceived fears—if the Soviets try to bomb us off of the planet all we had to do was duck and cover under our desks, and once the nuclear fallout had ceased we could head over to the vacant lot and play baseball.

Have you ever wondered how many waiting rooms are in the average hospital?  Those types of questions keep me awake.  There ought to be a plaque in each waiting room that reads, “This is where nothing happens.  Whatever you were doing ended, and whatever you need to do next has not started. Wait.”

One episode of Mad Men depicted a hospital’s waiting room.  The men and women in the room were dressed like they had just come from church.  I think waiting rooms led to the invention of magazines.  The sole purpose of magazines was to improve the experiences of the people doing the waiting.  Magazines were meant to distract patients from the fact they were waiting; you are not waiting, you are reading.  Dog-eared copies of Boy’s Life, Popular Mechanics, and Highlights were stacked neatly on the vinyl, avocado-colored chair next to the percolator.  After a while the nurse comes to get you, and there are times when you want to say, “May I have a few more minutes? I haven’t finished reading Goofus and Gallant in this eight year-old copy of Highlights.

Over the last fifty years we have seen dramatic changes in every aspect of healthcare except the aspect having to do with us as people.  People who have things to do other than wait.  Other than talk to you on the phone.  Waiting rooms have not been eliminated, but they have been upgraded.  And the upgrade makes for a much better distraction; it helps us forget that we are waiting.

Whether you are at the hospital for surgery, an outpatient procedure, or lab work, the very first thing you must do—before you pass GO and collect two hundred dollars—is wait.

So, after you pay for concierge parking you are directed to the waiting room, a room that now looks like a hotel lobby.  Today’s waiting rooms come with their own espresso bars and they provide free Wi-Fi. A flat-screen television will be hard-wired to some financial news channel.  You sit transfixed to some reporter speaking from the floor of the Stock Exchange, and you are mesmerized by how busy everyone looks as they scurry from one place to the next.  And you think, I bet the Stock Exchange doesn’t have a waiting roomEveryone there looks so busy. I wish I were busy.

As you drink your espresso you look around the lobby at all of the other waiters.  Your life is on hold.  You thumb through the pile of magazines; The Latin American Economist, Smithsonian, WebMD, and you think, I wish I were busy.

Out comes your laptop. By now your espresso is cold.  You gratefully log in to the free Wi-Fi. You pay all of your bills online.  To keep yourself from constantly checking your watch you begin to read the eight hundred emails in your spam folder.  Why am I waiting? You ask yourself.  They knew I was coming.  They were the ones who told me what time to be here.  There are twenty of us and only two of them.  The process reminds you of being at the DMV to renew your license, and you try to comfort yourself in the knowledge that the DMV does not have an espresso bar.

The matron in the tiny cubicle invites Mr. Jones to have a seat in her cube.  But I was here before he was you tell her.  “Did you sign in?” She asks. I tell her I did not know I had to sign in.  She scribbles my name to the bottom of her list, and she motions me back to my chair.

Thinking I am smarter than the average bear I call the hospital while I am at the hospital to reschedule my appointment because I want to be busy.  There are no magazines left to read. My spam folder is empty and my bills have all been paid and my espresso is cold.  The voice on the phone tells me the average wait time until someone speaks with me is fifteen minutes.  My call is placed on hold.

I am done.  I hand the concierge my parking ticket and he tells me I have to pay him ten dollars to get my car back.  But I have not done anything, I tell him.  All I did was wait.

Five dollars for the espresso.  Ten dollars for parking.  I could have stayed home for free.

My-Chart vs. Pie-Chart vs. Eye-Chart: Which Adds More Value?

I was showing my children photographs of me at a younger age; some of them black and white, affixed to heavy stock page that had yellowed over time.

Snapshots of what was.  Single depictions of specific events at specific times, none of them betraying or foretelling my future.  The photo album chronicled parts of my life, those parts captured by the pictures.  Some of the pictures are of my friends, mostly of my closest friends.

“What is that guy doing now?” My son asked about one of my track teammates.  I had no idea. We had not kept in touch, and I lost track of him.

White space exists on the album’s pages between each photograph. At times the white space serves as a placeholder covering a few days.  At other times the white space between the photos represented months or years.

To conclude nothing happened during the white space would be wrong. In fact, if I marked calendars showing when the photos were taken, less than one percent of the days would be marked.  Simply looking at a collection of photos spread across the years would serve as a very poor predictor of whom and what I would become.

My charts, not to be confused with MyChart, are scattered among four Philadelphia hospitals, my primary care physician, and a smattering of specialists.  Three of my hospital records are still paper-based since I was seen prior to the implementation of their EMR.  Not one of my charts gives anyone an accurate picture of my current health.  Each chart contains different data, none of the charts contains all of my data, and none of the charts contains any data beyond the date of my last visit.

I mention this because I think the health records of many patients are scattered like mine, like seashells among beaches.  If that is even remotely true, how then does a health system manage population health or my health or yours?

Do health systems participating in population health have what they need to effectively manage the health of the population or even of a single individual in that population?  Many systems are making big investments in Big Data as a way to help them drive the effectiveness of population health.  Health systems also point to the value of the EMR and how all of the data stored in the patient portal will facilitate managing the health of the population and the health of individuals.

But do health systems really have Big Data, or do they simply have a lot of data?  I think they have lots and lots of data, but I do not think they have the data they need to manage a population’s health, nor do they have the data to manage the health of most of the individuals within the population.

To be even remotely effective at population health management or running an ACO, a health system needs volumes of up-to-date data points on every individual, and they need that same volume of data on most of the individuals within their service area.  What health systems actually have are volumes of data all tied to a single date or dates for specific case or treatment, and the most up-to-date health data they have one anyone only reflects that person’s most recent appointment, treatment, or procedure.

Snapshots.  Old snapshots of health about a specific disease or treatment. The EMR has data describing how you were, it has no data describing how you are.

Suppose Sally had a negative mammogram last September.  How is Sally’s health today? Nobody other than Sally knows. And there are two reasons nobody knows:

  • Nobody has talked to Sally since September
  • Sally has no way of communicating her current health or her ongoing health to anyone at the health system.

The health data in Sally’s patient chart is static. Sally’s health is not static.  Her stored health data is no more informative than an old black and white photo pasted on the first page of her health photo album.

Population health management based on the data contained in the EMR is a non sequitur.  It is not logical to conclude that someone’s health, or that everyone’s health, can be managed effectively, or managed at all, without having the data needed to manage it.  If the most current information a health system has about the current health of a patient is based on data from nine month old mammogram, can the health system make any claims about the state of that person’s health today?

The problem with charts is that they are simply charts.  Snapshots of what was.  The white space between snapshots continues to be the issue.  A health system needs a means of storing the daily health data of each patient and consumer.  It needs a way to fill the photo album, a way to eliminate the white space and collect all of a person’s health events.

The health data stored on the smart phones of many people is more up-to-date and current than what is contained in their collective EMR charts.  People manually enter data every day about their diet and exercise.  Other data is recorded by their smart devices or by something they wear.  And then the people who own those devices play doctor, drawing conclusions about the state of their health based on how they interpret their stored data.

We already know that people given the chance to record and track their health data will do so faithfully.  We also know that many of the applications people use for managing their health may have been developed by two teenagers working out of their basement.

Why doesn’t your health system elevate the importance of managing my health and yours and get it out of the cellar by doing the following?  Design healthcare apps to:

  • Capture, track and manage my health data
  • Have a great user interface and to deliver a great user experience
  • Communicate my data among the various apps
  • Populate my health record with the data
  • Provide a way for the health system to evaluate my data and to notify someone if that data suggests I should be seen.

When my health system does this it can begin to proactively manage my health. And it can manage the health of consumers, people who have never been their patients.  If two teenagers in a basement can do this, can’t our leading health systems?

Are Patients Dying For You To Improve Patient Access?

Many years ago I attended a business technology convention whose keynote speaker was the CEO of the largest U.S. cable television provider.  A reporter asked the CEO why cable television subscriptions had capped at seventy percent of U.S. households. The CEO replied that older people did not subscribe to cable.  The reporter then asked the CEO how the industry would deal with that situation.  The CEO stated, “We are waiting for the older people to die off.”

Healthcare does not have the luxury of waiting on anything.  Some people in healthcare pretend the issue of whether to apply technology to patient access is irrelevant because they have patients who do not use technology, people who do not use the internet.  Indeed there are patients who are more comfortable accessing their provider by phone.  However, the converse is true, and it is true in much larger numbers.  Applying technology to improve the patient access experience is not a binary trap, it is not an either or situation.

One of the great things about technology is its impartiality. Technology, when applied to patient access does not take sides, and it is relatively difficult to hurt its feelings.  Plus it has a great memory—it gives the same response, the correct response, every time to the same question.  Technology makes access easy for the patients and consumers, and it makes it easy for the health system.

Foresight versus hindsight.  How difficult would driving be if the only view available to the driver was the view from the rearview mirror?  Three years from now the best hospitals will look back at why the question of innovating patient access was ever in doubt.

Three years from now the other hospitals, the ones constantly losing patients, will look back at the question of innovating patient access and wonder why they didn’t do it.

Patient Experience: You Won’t Believe This Conversation

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

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

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

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

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

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

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

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

The two categories of leakage of patients and consumers are:

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

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

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

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

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

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

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

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

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

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

CMS Measures HCAHPS, What Do You Measure?

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

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

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

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

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

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

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

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

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

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

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

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

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