Improve Patient Access: Close Your Call Center

“The first thing we do, let’s kill all the lawyers,” Shakespeare, Henry VI.

No small feat considering the number of lawyers. Rather than take such a radical step, let us begin with something more achievable.

Let’s close all the health system call centers. Customer experience may go up, and customer access may not be affected negatively.

Now that everyone is paying attention, perhaps we could spend a minute or two looking at why that may not be such a bad idea—the call centers, that is, not the lawyers.

A few warm up questions for the executives in the audience. Do you know the location of the call center? Have you visited it in the last year? When was the last time you eavesdropped on a few calls?

I have done this so often that at times I feel like Frank Bruni, the gentleman who writes the restaurant reviews for the New York Times, trying to surreptitiously offer a sensible review without being outed.

Most of the hospitals I have visited whose leadership believes has a call center, does not have a Call Center. They have a place people call. In ninety-percent of those centers what they actually have is a place for people to call to schedule appointments. They have a scheduling center, and rarely does the scheduling center even do a good job of scheduling calls.

It is worth noting that only twenty to thirty percent of callers call to schedule an appointment. The other seventy to eighty percent of calls have nothing to do with scheduling. And the people answering all of those other calls know very little about providing the caller with the correct answers to all of those other calls.

That means if your health system receives a million calls a year more than three thousand calls each day have to be transferred to someone who may know the answer and who may have the tools needed to help them answer the caller. (The daily number would be less if callers could speak to someone on Saturdays and Sundays, but then I would be being silly even to suggest that.)

On the flip side, we have two hundred thousand people calling to schedule something or another. I would guess that less than sixty percent of those callers have their needs met the first time they call. Adding the two categories of disappointed callers gives a number of around 900,000 calls that result in an unsatisfactory experience. At a fully-loaded cost of around thirty dollars a call, which means that health system will spend about twenty-seven million dollars to underwhelm its customers and prospective customers.

Surely less money can be spent to achieve the same result. One way to do so would be to close the call centers and disappoint everyone at zero cost to the health system.

Here is what I observe health systems are doing to try to improve the caller’s experience. They hire more call center agents, and they throw technology at the problem, technology like scheduling applications. Applications that do nothing for the other 80% of calls. Applications which without an understanding of the business problems, without a strategy and a plan, will get in the way of creating a great caller experience across the enterprise. They debate centralizing or decentralizing the places from which they answer calls. They debate implementing a single number for anyone to call about any thing.

“We don’t know where we are going, but we are making really good time.”

Perhaps the time has come to decide what the business reason is for having a call center, to decide what business problems the health system wants to solve through the call center.

People are going to call the health systems whether or not the health system has a real Call Center. There are real costs associated with having a call center that can do what needs to be done. The good news is that those costs pale in comparison to the costs of having a call center that does not do what needs to be done.

The best reason for doing this correctly is that a functional call center is the health system’s most valuable point of contact for retaining patients. Or it isn’t. chances are that the one currently being operated by the call center is not doing the health system any favors.

And once you have fixed the call center, then we can think about what to do with the lawyers.

Is Your Health System Increasing Patient Experience Or PX Scores?

On Friday I had a chance to speak with someone who reads this blog.  He mentioned that my style of writing seemed a little edgy.  I appreciate that he chose such a polite word.

It was too cold to go out, too cold to play ball.  So we sat in the house and did nothing at all.

So starts The Cat in the Hat.  So started my day.  For those unable to recall the book, a cat enters the kids’ home…yada, yada, yada…and pretty soon everything in their home is covered with pink stains.  The kids know that their mom will be home soon and that the house must be spotless before she arrives.

I am the Rain-Man of parenting, an idiot savant wannabe.  My cat-in-the-hat moment occurred this morning.  Permit me to set the stage.  Last night our sixteen-year-old had his friends over for a party.  I was flying solo; my wife was out of town.

The first indication that something was amiss was when I tried to find the kitchen this morning.  From what I was able to recall the kitchen was somewhere beneath the compost pile and Williams-Sonoma warehouse that covered every inch of granite countertop.  The air was a haze of Snapple—Utz—Buffalo Wings.  The entire first floor looked like Animal House’s Delta Tau’s frat house run amuck.

My son was twenty-four hours away from being sent to boarding school in some country not covered on the National Geographic channel.  My message to the boys was simple, little cat Z was about to have a very long day. Mom was one her way home.  You need to be as frightened of her as I am.  I have your phone, I told my son.  You will get it back after you graduate Georgetown Law.


Improving patient experience.  Improving patient experience scores.  Two entirely different missions.  They involve different teams; different tasks, different scorecards and they have different outcomes.

One scorecard enables the health system to declare victory if it spends a lot of money and bumps it up by a tenth of a point.  The other measures success in $200,000 increments–the lifetime value of a patient.  A retained patient, a referred patient.

The focus of most health systems is getting the next tenth of a point.  The focus of most health systems ignores their largest stakeholders, people.

Perhaps there is merit in refocusing.

Why is a Accessing a Health System like Buying a Shovel?

Today’s question. If a consultant walks into the woods and falls down—they cannot fall up, so the word ‘down’ is wasteful—does the consultant make a sound?

I thought we could being today’s post by asking everyone to take thirty seconds—you won’t need forty—to go the website of your favorite health system and complete all of the tasks or business functions the site lets you perform.

I am willing to bet that on more than ninety percent of health system websites the only interactive task (a task where you can actually enter data) available to you would be clicking “Like” on the health system’s Facebook page.

Why do I like harping on this issue? Suppose you purchase a shovel from Home Depot. The reason you bought the shovel is because Home Depot does not sell holes. If you have a think about it, you will find there is actually a lot of depth to that statement.

“This is my shovel. There are many like it, but this one is mine.”

You take the shovel home, and you see that there is a pamphlet taped to the shovel’s handle. The pamphlet tells you all about the history of shovels. It describes the different types of shovels. There is information about how to go to their website and select a shovel. It tells you about the company that manufactured the shovels, the people who are on the board of the shovel making company, and about all of the different tools they make. There is even a sentence telling you what hours you can call the manufacturer if you have questions about your shovel. And, there is a paragraph in the pamphlet about touring the shovel manufacturer’s plant, and the hours the shovel gift shop is open.

After reading all about shovels, you notice that a blunt safety device has been attached to the business end of your shovel. You cannot use the shovel until you remove the safety device. You try a number of ways to remove the device but you cannot get it to budge. You then reread the pamphlet to see if you overlooked the information about removing the blunt object. The information is not there.

Where does that leave you? It leaves you knowing everything about your shovel but without a way to use it to benefit you. The utility you gained from reading the pamphlet just nosedived. There is no reason to ever read the pamphlet again.

Now think about your health system’s website. Chances are it is a lot like your shovel pamphlet. People—customer people and patient people—can read about the history of the health system, they can read who is on the board, read about the different services—shovels—the system offers, read about the gift shop and about taking a tour. They can read about what hours to call the organization. Heck, anyone who is interested could read about the health system for hours.

However, when they are done reading, they are done. There is no reason for them ever to return to the website because there is nothing for them to do when they are their. In most health systems the only reason for a person to visit the website more than once is if they forgot to “Like” the system on Facebook during their initial read-through.

Access is absolutely worthless unless your customers can do something once they have accessed your health system.

The great features of accessing a health system through its website are that there are no wait times, no dropped calls, and no wrong answers.

The bad feature of accessing a health system through its current website is that once you have been there, there is no reason for you to ever access the health system through its website again.

Every health system has a website, but it often seems that few people have asked the question, ‘Why do we have a website?’ I think too many health systems built their website because someone felt a need to check the ‘We have a website box.’

More people—customer people and patient people—go to your website every day than ever walk into the health system’s expensive lobby. Yet nobody pays any attention when they are designing the website to the fact that people go to the site hoping to be able to do something.

They go the site hoping to avoid calling the health system. They do so because they have tried calling on other occasions, and that experience was painful. In all likelihood, the people who designed the website have never tried calling the health system. Had they tried calling, they would have designed the website better. They would have made access to the health system a priority. They would have made it actionable. They would have made it a place where people—customer people and patient people—could accomplish any task they set out to accomplish with the possible exception of having their knee replaced.

And the really silly thing is that when hospital executives go the websites of other vendors they use—vendors like airlines and hotels and phone companies and retailers, they go to those sites to accomplish tasks.

Roemer’s Immutable Patient Experience Laws: There are only two types of people who go to a health system’s website; those who are deciding will I buy healthcare from this provider, and those who are deciding will I buy healthcare again from this provider.

Please permit me to offer an observation. They go to the website with the expectation that they will be able to handle tasks like Referrals, Authorizations, Registration, Scheduling, Refills, Triage, Billing, Payments, Admissions, Discharge, Disputes, Claims, Insurance, ED, Labs, Primary Care Provider, Clinics, Medical Records, Imaging, Therapy, Pre-surgery, Find a Doctor, Payment Plans, Pharmacy.

They leave the website, never to return, because they could not accomplish anything. Never to return. Never to be a new patient. Never to be retained as a patient. Never to refer the health system to anyone.

The lifetime value of the person who had a bad experience is around $200,000 dollars. The lifetime cost to the health system that provided the bad experience is around $200,000.

Multiply that by one hundred disappointed patients a year and all of a sudden the cost of not providing good access is pretty high. The good news is that all of these problems can be fixed.

Shift Happens: How to Dramatically Reduce Readmission Rates

Renee Letourneau’s recent article, “Realizing Readmissions Goals’ in offered interesting snapshots of the efforts of a handful of providers. The purpose of today’s post is to suggest a way to dramatically reduce the number of readmissions.

Two important criteria about achieving goals are; you have to set a goal to hit it, and the higher you aim, the more likely you are to hit something noteworthy. An example of a poor goal is ‘we do not want our readmissions to be any worse this year.’ What then is a noteworthy goal? Reduce readmissions by 2%, by 3%? What about reducing it by 20% or 30%?

Many of you may be questioning my sanity, or your own for reading this post thinking, “Don’t you think that if a twenty-percent reduction was possible that we would be doing that?

As you know, except for when I have been a patient, there is nothing clinical in my background. So I understand if your initial reaction to me writing about reducing readmission is chocked full of skepticism. Mine is too, but try to bear with me.

One area where there seems to be uniform agreement is that readmission rates haven’t moved much, and there is little indication of the rate declining noticeably any time soon. And that got me wondering; what if we change how we look at the problem? What if we shift our approach to solving it? Big problems require big ideas.

Once the patient leaves the hospital, other than a call from the hospital to the patient, the health system has zero access to additional information about the discharged patient’s health. Our only control over whether the patient will be readmitted is whether the patient complies with his discharge orders, and health systems have zero control over that.

Since we know that none of the efforts to reduce readmission rates has brought about monumental change, why not ask the question, “What would we have to do to reduce readmissions by twenty or thirty percent?” My guess is that having real-time, 24 x 7 information about the health of each discharged patient would be a big help.

What if instead of sending discharged patients home, we sent them to the floor of the hospital whose sole charge was to observe discharged patients? And on the floor we would observe and record information about each patient on the following; did/does the patient:

  • Take his medication as prescribed (I am not going to write ‘his or her’ medication for each bullet point because doing so would irritate me. If it makes you feel better to insert it parenthetically, have at it.)
  • Have a fever
  • Have any side-effects or complications
  • Manage his diet
  • Adhere to his discharge orders
  • Exercise
  • Schedule his follow-up appointment

As we observe and record the information, if something in a patient’s data raises an alarm, we are able to react to it. No new data, no reaction. one we have the information we can stop the problem from becoming worse. If we knew all of the information for each discharged patient for some fixed period of time, would we expect readmission rates to decrease? Of course we would.

We agree that knowing more about a discharged patient’s health after the individual is discharged would help reduce readmissions, perhaps even significantly. But it is unrealistic to create a ‘discharge floor’ for patients, so strike that idea. We could call each discharged patient every hour of the day but after about three calls both parties would hate that idea. So what is left?

Roemer’s Immutable Law: To reduce readmissions by 20%-30% we need 24 x 7 access to the discharged patient’s health information.

We do not have it.

We cannot get it.

What if there was a way for the provider to access the information it needs to enable the provider to manage the discharged patient’s health?

There is. The patient could provide it.

This solution should be designed to provide the same functionality and access as the discharge floor. The only way a solution will work is if the solution’s User Interface and User Experience are exceptionally good. I see it working something like this:

  • At discharge the patient is given a secure login to access the provider’s discharge portal—think of this portal as being the provider’s robust, online interactive Discharge App.
  • The Discharge App lets the discharged patient access the hospital using a computer or smart device 24 x 7
  • The Discharge App allows the patient to:
    • Enter the information the provider needs to manage the health of the patient
    • Access a variety of clinical and business processes
    • Access educational information about his illness or procedure
    • Access a clinician via email and online chat
  • The Discharge App allows the provider to:
    • Collect the data it needs
    • Assess the data
    • Determine if the data triggers an alarm
    • Determine if the patient needs to be called or needs a visit from a clinician
    • Reduce readmissions

This same idea would offer similar benefits in Population Health Management.

If you are interested is viewing a very rough mockup of what the Discharge App could look like, click on this link.

I would welcome your feedback, positive or negative.

Something lite on trying to eat healthy

I mentioned that I am participating in something dubbed the Whole Life Challenge.  Fifty-two days eating nothing but air.  Trying to get into the spirit of the event, I went shopping at a whole foods store. From the outset, I sensed trouble, for the phrase ‘whole foods’ made no sense to me. Had I been eating ‘half foods’ my entire life?

The display case near the door had small bags of something called ‘Bark Thins’—second sign of trouble. I slipped past the bark without having to avoid stepping on any leaves or acorns.

Knowing I had to cut back on what I liked to eat, I thought I would add some flavor to what I had to eat to complete the challenge. I went to the aisle that displayed various flavors of oils in a way that reminded me of how an upmarket wine store would display its choice Beaujolais.

I inquired of the oil sommelier where I might find black truffle oil. The truffle oil was in a locked display case, in bottles the size of what you would find in your hotel minibar. When I saw that they were priced at an amount one might expect to pay for a whole truffle, I understood why the bottles were under lock-and-key. Perhaps the truffle-finding-hogs in France’s Périgord region were used to stomp the oils from the rejected tubers.

My stomach was starting to rumble, so I asked for directions to the meat emporium. The employee from whom I sought help had hair the consistency of the threads covering a coconut husk and organic metal implants threaded through both eyebrows. I asked her if she was a vegetablist.  She did not attempt a smile, and reluctantly showed me to the meats.

If something without opposable thumbs flies, swims, hops, crawls, or walks, I’ll eat it.  I will sauté, braise, roast, grill, poach, stir-fry, boil, broil, escallop, fricassee, parboil, or simmer anything that strikes my fancy, especially if it has hooves.  I like meat—the smell, the taste, the texture, and how it appears on my plate next to a sprig of cilantro.

Permit me to ask the carnivores who may be playing along, “Have you ever walked into a dinner party and introduced yourself with anything close to the following? ‘I’m republican and a carnivore.  May we slaughter the fatted calf?’”  Probably not, but I was sorely tempted to ask that of my vegetarianess tour guide.

The whole foods meats did not look like they were sold in whole portions. Each piece of meat could have fit nicely on a Wheat Thin, with plenty of room left over for a gherkin. A tablespoon of au-jus would have drowned the petifore-sized comestible.

Thirty minutes into my adventure, the only item in my organic basket was my truffle oil miniature.  I was tempted to purchase some raw macadamia nuts until I realized that the price was for an ounce rather than a pound.

All in all, I am looking forward to the next forty-nine days and seven hours of this exercise. As I was paying for my truffle oil, I asked the clerk if they had any organic, beef-flavored gum. She, too did not find me amusing.

Adding insult to injury, I had to pass a McDonalds on the way back to my car.

PX for Medical Practices: Is it a Zero-Sum Game?

This is day one of a ninja whole life challenge I entered. I began it with an omelet of egg whites without the whites, a sweet potato sorbet, and two bottles of dehydrated water.  After breakfast I had a massage; my first.  The room looked like an organic bookstore, and smelled of a collection of herbs and oils from the Far East, perhaps as far east as Newark. The CD played an infinite loop of soft sounds that reminded me of a yak herder and a wood nymph playing panflutes in the Andes, who I imagined was wearing a poncho woven by vegetarians, made from hand-carded wool of Peruvian alpacas.

Apparently, forty-thousand people have enrolled in the health challenge. I am willing to bet that I will be the only one needing a mulligan on day one as I am headed to an all-you-can-eat crab feast for dinner. Perhaps the fact that I will be eating seafood means I can collect a bye.


Around seventy percent of all interactions between a medical group and a person—patient/customers—occur on the phone. Not really surprising except for the fact that many medical groups and health networks treat patient experience as a poor stepchild, especially when it comes to the people on the phone.

So let’s say that thirty-percent of the interactions, those done in-person at the medical group provide an unbelievably good experience.

The other seventy percent of interactions are a combination of random experiences that provide the caller with levels of satisfaction such as:

  • “Our office is closed at the moment…”
  • “We are at lunch between…”
  • “May we call you back?”
  • “May we put you on hold?”
  • “Dr. Roemer is not accepting new patients.”
  • “We do not do refills over the phone.”
  • “The person who handles billing is out today”
  • “Can you arrive early to fill out the forms? No, they are not available online.”

Is it really cheaper to invest so little in the experiences provided on the phone? Do providers have such a hold on their past patients that those patients would never consider going somewhere else?

Many executives continue to look at calls and callers as a cost or cost-center. Many of those same executives spend money to make outbound calls to attract patients. It is a zero sum game to attract patients only to send them away. Here is another one of Roemer’s Immutable Laws:  Calls and callers are not a cost. A poor call experience is.

Some health networks approach improving the situation the same way they handle improving their HCAHPS scores—they hire a firm to try to throw a little water on the problem; they hire a consultant and coach. And what do the expensive consulting firms and coaches do for them? From the confines of my small mind I would say not much.

For the most part, coaches sell smiles. When you are speaking with someone on the phone, make sure they hear you smile. Now there’s a value-add.  Here’s another one of Roemer’s Immutable Laws: A smiling phone agent is worth less than zero if the agent puts you on hold, transfers your call, or gives you the wrong answer.

Many call center consultants will attempt to solve your problems by telling you your solution can be found by adding technology and speed—efficiency. Too many people are on hold and too many people are abandoning the call—disconnecting. If that is how they view the symptoms they will propose one of two solutions—hire more agents (to spread the workload) or have your call center agents, the people answering the calls, talk less, thereby allowing them to talk to more people.

Neither of those answers will improve the experience for the callers.  What will improve their experiences are the following:

  • Design the caller’s experience
  • Give the people answering the phones the tools they need to provide the caller with the right information
  • Add a self-service IVR to allow callers to get what they need without having to speak with someone
  • Offload certain call types to the web to allow callers to do what they need without having to call you

Or, you can simply give callers the phone number for the Minute-Clinic.

Please consider joining  the LinkedIn group, Patient Experience Think Tank

What are Patient Experience’s 3 Immutable Laws?

I was observing the heads of my fellow passengers on the Amtrak train.  As the train angled left, the heads of the people in front of me leaned in unison and unanimously to the left.  An angle to the right yielded a similar bobble-head response to the right from everyone. For some reason the action and reaction I witnessed reminded me of a lot of meetings I had attended.

As I took my new MacBook Air out of the box, I looked to see if I had misplaced the operating manual. I found a piece of paper somewhat smaller than a cocktail napkin.  Instead of the words “Instructions” or “Manual” the piece of paper simply stated “Designed by Apple in California.”

Enough said.

User Interface. User Experience. Designed by Apple in California.

My first user experience with anything from Apple was several years ago when I downloaded iTunes. I did not know how to use it then. Because the user interface for iTunes delivers such a poor user experience I still do not know how to use it. In fact, I never even try. After three decades on a PC, switching to Mac feels like learning to use a fork with my other hand.

Two products from the same company. One requires no manual, the other requires a tutor to follow me around. Everything comes down to how easy is the product or service to use. Most people will not invest much time to learn how to use anything.  They will however invest time to find a similar product or service that is easier to use.

One of the services with which we are all familiar is healthcare.

Roemer’s First Immutable Law for Providers: Designing Access is the Most Important Initiative You Can Undertake.

The first time most people—patients and customers—will ever encounter your organization is when they try to access it, when they try and have a meaningful interaction with it. Here are components of Roemer’s 1st Law:

  • If your phone is busy your callers will hang up (feel free to add the words “and call another provider” to each of these)
  • If your callers are placed on hold they will hang up
  • If their call is transferred they will hang up
  • If their needs are not met when they call they will…call another provider
  • If I go to your hospital’s website and the link for the Gift Shop is as prominent as the link for Patients they will go somewhere else
  • If your website has dozens and dozens of links and nothing for them to do they will…go somewhere else

And who are these people who are calling and going to your website?  Roemer’s 2nd Law: Every caller and reader of your website is a potential patient.

Most website visitors are not patients. Thousands of the callers are not patients. These people include the sick, the well, people who are concerned they may be sick, family members, visitors and people at Starbucks.

The reason they are trying to access your hospital is that they want something from it. They may want healthcare. They may want to talk to Aunt Irma in room 312. Roemer’s 2nd Immutable Law For Providers: Patients and Customer do not want to have to work hard to get what they want.

Why is that? It is because nobody designed stickiness into the experience, into the user interface. Stickiness is created when someone interacts with the organization and comes away saying, “That was okay”, “That was really good”, “That was worth my time”, “That was remarkable.”

For almost every hospital, someone going to your hospital’s website is not an exercise in access because there is nothing for them to access; it is mainly a reading exercise. See spot run. Aren’t we a great hospital?  No reason to have gone to it and certainly no reason for anyone to go to it a second time.

Roemer’s 3rd Immutable Law for Providers: If you make me work hard to do business with you I will go somewhere else.

Each caller and website visitor has a potential Life-Time Value to a provider between $180,000-$250,000.  Your hospital may employ a hundred people in marketing and business development. Their mission in life is to try to get people to call the hospital and to go to the website.  Why spend a great deal of money to entice people to check out the organization if people are going to have a poor experience? When people make the effort to visit you, if they have a less than stellar experience they will leave.

Patients leave before becoming patients and they “leak” after receiving services. That seems like a very unsustainable and expensive business model, especially since nobody knows how many or why or when people leak, or which ones do not call back or return to the web site.