Healthcare’s Narcissism–Nobody Wants to Call You

The Real Portlandia

Portland, Oregon; where moss grows on moss.

If you have ever seen the movie Apollo 13, you may recall the scene when the capsule containing the three astronauts passes behind the moon where the sun is no longer visible. Once a year, Portland has its own Apollo 13 moment.  The sun disappears, not to be seen again for five or six months. Did I mention that is rains here? I Googled to find plans to build an ark.

I wrote to Portland’s mayor and I proposed that he create an annual city day of mourning to commemorate the last day that Portlandiers see the sun, the day we put away our sunglasses.

Don’t get me wrong, I adore Portland. There is almost an antediluvian feel with regard to some of the unintentional entertainment value of the city. It is not unusual to see the machinations of Portland play out like a Lifetime movie.

There is a female author in Portland whose self-published works include, How to Murder Your Husband, Girl Most Likely To, and The Wrong Husband. In an interview, the author, describing her work, said, “Which means my husband has learned to sleep with one eye open.” The police arrested her last week for—say it with me—murdering her husband. Her yet to be published work, which she will have plenty of time to write, should be titled, Forty Years in Jail.

There is a certain catharsis that comes from writing. An even greater catharsis that comes from murdering someone using ones and zeroes. I know that of which I speak—I know that was a bad sentence, but those of you who have been reading my blog for a while know I am not an astute grammarian—because I’ve written two novels both of which gave me several cathartic moments.  But I have never exercised the catharsis in real life. Yet.

I enjoy watching true crime stories on Discovery ID simply because after watching the show I feel smarter than I did before I watched the show. A spouse dies.  The police discover that the surviving spouse purchased a seven-figure life insurance policy on the deceased spouse the day of the death. Dumb and dumber.  It’s not exactly a who-done-it.

Segue.

Too many providers are trying to build watches to understand consumerism. Unfortunately, none of them have any experience building watches.

The neo-watch-builders have reset their call center IVR to the following:

  1. If you want a single payer system, press ‘1’ and your call will be transferred to Bernie Sanders
  2. If you want to single payer system today, press ‘2’ to be transferred to Canada’s immigration system
  3. If you believe in global warming, press ‘3’ to be transferred to Barbara Streisand
  4. If you want to do something other than schedule an appointment, press ‘4’, click your heels together three times, and chant, there’s no place like home
  5. If you went to our website to do anything other than finding out what hours our gift shop is open, press whatever you wish because we can’t help you
  6. If you went to our website to donate, press ‘5’ and we will send someone to your home to pick up your check
  7. If you want to speak with a clinician, press ‘6’ to listen to the recording that says someone will get back to you within 2-3 days
  8. If you do not want to press ‘6’, hang up and go to the Minute Clinic
  9. If you clicked ‘contact us’ on our website, repeat step 7
  10. If you want to solve this problem, press ‘7’ and you will be connected to the Senior Hallway Monitor

Whether you are a provider or a payer, nobody ever wants to call you. They call because they have no other option.  Did I mention that I am the Senior Hallway Monitor?

There are solutions that are better than trying to learn to build watches.  If you are interested in learning what time it is, call me.

 

Don’t deliver bad news this way–A true story

This will tie together in ninety seconds.

While I was on vacation my mother and brother were taking turns checking on my house and bringing up the mail.  My brother called three days into my trip, and told me that cat died.  I said, “You can’t just drop that kind of news on someone.  You have to work up to it gradually.”

“And how should I have done that?” He asked.

I said, “You start off slowly, maybe saying something like the cat got out and it climbed up the side of the house, and now the cat’s on to the roof, and it won’t come down.  And you tried to get it down using a ladder, but the ladder was not long enough.  Then you say you called the fire department, and a guy got hold of the cat, but the cat jumped out of his arms and died. See? You ease into it instead of just dumping the bad news.”

Two days later I called him again.  “How is everything going?”  I asked.

He was quiet for a few seconds, and said, “Mom’s on the roof, and she won’t come down.”

In this analogy, I am the mom.

Having moved Portland, I had to change healthcare providers. My provider of choice back home was Penn Medicine, the Gold Standard of superb care. My new provider is a very, very large system. I won’t name the system except to say that its name is spelled the same way as a popular sandwich roll and the name Germany used for its emperors.

I was originally going to write a post about this health system because of its efficiency.  They have six-sigma-ed everything. It runs like a Toyota factory. The premise of my original piece was to ask the question, ‘Is possible to make the healthcare experience so efficient and so machine-like to make a patient wish it was less effective?’

Can you engineer the digital patient experience of a health system to a point that the digital experience actually degrades the patient’s experience? It is possible to take the humanity out of the care? In a very efficient system, does the patient simply become a number, like a part number in the Toyota factory?

Even prior to what happened at 10:54 last night, my conclusion would have been, yes. To borrow a line from Blazing Saddles, “Mongo only pawn in game of life.” To me, it felt like there was care, good care, but without caring. Had this health system gone too far? Was it possible to reengineer every business process to such a level that in doing so they eliminated the humanity?  Short answer; yes.

December 8, 2002. I had a heart attack. My cardiologist at Penn Medicine called me his poster child for recovery. I became a walking health nut. I exercised six days a week. I did not eat anything that came in a box or a bag or a can. My resting heart rate was 60 beats per minute. I was even invited to be part of Penn’s Cardiovascular Institute—I think they needed someone to serve the coffee.

Back to Portland. I’ve been an avid runner since high school. I’ve always been able to run for hours. Late last fall I learned that I had a slight tear of my meniscus and a hairline fracture of my tibia. I stopped running for several months. I resumed running this April. I have tried to run 5-6 days a week since then. Last week I told my new primary care doctor that I kept hitting a wall before I finished the first mile.

He listened to my heart. He listened long enough to have me concerned. “You have a heart murmur,” he said. And he ordered tests—an EKG, a chest x-ray, and an echocardiogram. In fairness, I should add, I am very impressed with him. If I could have hand-picked a PCP, I would have picked him.

That said, when you have had a heart attack, and your doctor starts ordering tests concerning your heart, the hairs on the back of your neck start to bristle. The hairs on the back of my neck were doing backflips. Alarm bells were ringing in my ears.

Ever since Al Gore invented the Internet, we’ve all been there. The moment you sense that something is out of sync with your health, you hit up Google, and self-diagnose. As a person who has had a heart attack, every time you feel the slightest twinge you become alarmed. It goes with the territory.

10:54 last night. “You have a new message from your healthcare provider.” The result of my echocardiogram was available less than fourteen hours after the test. Very efficient. I’m sure the health system had spent a lot of money on consultants. The consultants had designed a way to eliminate every wasted second. They had also designed a way to eliminate the caring from the care.

I read the message at 10:56. “The reason that you are having trouble with your stamina is that your echocardiogram shows that the left side of your heart is enlarged.” That was the entire message. The message was very efficient. Just the facts. No extraneous words. No explanation of the implications of having an enlarged heart for someone with heart disease. No offer to ‘call me to discuss this.’ Nothing to tell me whether it was okay to run today.

“Mom’s on the roof and she won’t come down.”

10:57.

10:58. Go directly to Google. Do not pass Go. Do not collect $200. Enter the search term, ‘enlarged heart.’ 71,700,000 hits. None of them were favorable enough to give me a good night’s sleep. I read the first three million results.

Cardiomegaly. The word itself is enough to keep you from sleeping. If having an enlarged heart was good news, they would not need to create a fancy word to disguise the problem. In the world of Google, by 11:04 I ascertained that the state of my health was somewhere between needing a heart transplant and being told to quit exercising.

11:06 I am checking symptoms. Shortness of breath. Swelling of legs. Weight gain.

By 11:07 I am wishing I had not read the message.

By 11:08 I am wondering why the message did not tell me to call my doctor.

By 11:09 I have placed my vial of nitroglycerine pills on my nightstand.

I consider myself fortunate to live in a country that offers the best healthcare in the world. I also consider myself to be an expert when it comes to patient experience and customer experience.

I have no worries about whether my current health issue will be managed correctly. I do, however, think that the notification of my current health issue could have been communicated better. Since my doctor didn’t offer any advice, I went to CVS and bought a bottle of Flinstone vitamins.

Update 4 days later: I used MyChart and messaged my doctor twice asking what I should or should not be doing and how concerned I should be. No reply.  I would have called him but the system does not provide his number. Care without caring.

However, I emailed my Penn cardiologist and he replied within an hour. Care with caring.

My advice to my new provider comes from the movie Bambi. “If you don’t have something nice to say don’t say anything at all.”

What is Healthcare’s Black Hole?

The temperature was in the mid-nineties.  Nine miles into my run I was approaching the crest of one of the many bridges that crossed the Clackamas River near Portland. I was leaning over the guardrail to catch my breath. I was dog-tired, dehydrated, and my feet felt like they had swollen to twice their normal size.  (Getting older sucks, but it’s better than the alternative.)

To my surprise, an Oregon state policeman kitted out smartly in his pressed uniform and wide-brimmed hat, pulled alongside me. He rolled down the car’s window. “What are you doing on my bridge?”  He asked from the cool confinement of his air-conditioned patrol car.  There was an undisguised tone of concern in his voice. To hear what he was saying I paused Roy Orbison’s Running Scared and I removed one of my earbuds.

I saw my face reflected in his Ray-Ban Aviator sunglasses.  Since I was trying to cross the bridge, I thought about asking him if he had any ID to prove that he owned the bridge, but he did not look like he was in the mood to play games.

“Are you okay?” He asked me.  “You don’t look okay.”

“I’m fine. Why did you pull me over?” I asked. “Was I running too fast?” He was not amused by my attempt to engage him in meaningless banter.  “I just heard on the radio that a guy looked like he was ready to jump off my bridge. I got several calls about a guy on the bridge who looked depressed. Are you thinking of jumping?”

“Am I thinking of jumping what?”

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

“I think I look like I just ran nine miles.” I placed my right leg on the top of the guardrail to stretch my hamstring.

Eighty feet below me a small armada of boats had dropped anchor and the boaters appeared to be having impromptu tailgate parties in the middle of the bay.  Everyone was looking up at me, and some appeared to be filming, so I waved. I heard a few of the boaters yelling for me to jump.

I also heard the thwump-thwump of a television news helicopter as it hovered overhead, its parabolic microphone pointed in my direction. (I embellished my story a little to make for a better blog, but it’s my blog so I can write whatever I want.)

“Take your leg off my guardrail,” he ordered, “and back up slowly.” “I was about to call for a police helicopter and rescue divers. Are you sure you are okay?”

I was going to ask him if his helicopter would give me a ride home, but he didn’t look like a ride home kind of guy. If I continued across the bridge, my home was only two miles away.  If he did not let me cross the bridge I had to double-back those same nine miles. “May I continue across?”

“No, you can’t do that from here.”

An interesting statement, You can’t do that from here.

Segue.

I was analyzing a hospital’s website. There was a link on the homepage stating that if I clicked it I would be able to schedule an appointment. (It was right next to the link telling me that if I clicked it three times I could continue across the bridge and go home.) There’s no place like home…

I clicked the scheduling link. The next webpage told me how much they wanted to help me schedule an appointment and how important my health was to them. The following webpage told me about all the services I could schedule. The final webpage told me that if I wanted to schedule an appointment I should call the hospital Monday through Friday between eight A.M. and five P.M.

The website’s scheduling web page should have included a 24-point, bold disclaimer stating, You can’t do that from here. Like trying to cross the bridge.

Healthcare is the only industry that requires you to have a phone to do what you want to do.

 

Healthcare: Please Don’t Make Me Call You

Nowadays you can’t swing a cat without hitting someone who has a newer and better idea about how you can fix your organization. More often than not, those ideas include the word design: user design and human-centered design are two of the culprits.

And that is the problem. Every business process in every firm is the outcome of human-centered design. Somebody—a human—designed it. And chances are very good that they did not design it well.

Instead of thinking, ‘How would I design this?” executives need to be asking, “How would other people—humans—want to use this process?”

To be effective at what they do, firms need to go from user design to user-centered-design. They need to go from human design to human-centered design. When talking about what makes one business more effective than another business, one word, centered, makes all of the difference.

I’ll use healthcare to illustrate the point, but the same issues apply elsewhere.

If you have ever called your payer or your provider, you know what I am talking about. Whoever built the call center you called spent way more attention selecting the color of the carpeting that was installed than they did figuring out how to solve business problems.

The same logic, minus the carpeting, applies to their websites.

Nobody ever sat down with a patient and asked, “What do you want to do, and how do you want to do it when you contact us?”

Neither did CMS when it came up with its list of what constitutes a good patient experience.

If you are a healthcare executive, consider doing this. Sit down with a patient, and have the following conversation.

Executive: “What do you want to do when you call us?”

Patient: “I do not want to call you.”

You can take it from here. If you get stuck, let me know.

Would CX Be Better If You Spoke British?

I have no segue to offer you in this missive. What follows are the incoherent musings of my drive-by-mind. If you know how to play Guitar Hero, the next two minutes of your time may be better spent doing that. If not, let’s just agree to tough this out together.

I wrote a few weeks ago that I had auditioned for a play and that the theater for which I auditioned is going to pay me to accept the part. It’s okay to laugh…I find it equally amusing. Maybe this consulting thing I’ve been doing for the last thirty years has been no more than a placeholder until I discovered what I wanted to be when I grew up.

Having said that, a week from Saturday I am auditioning for another play, a British comedy. Between now and then I have to develop a posh English accent. Whilst versus while. Let’s have a cuppa tea. I have an MBA from a rather up-market university. None of the people with whom I graduated are spending their downtime memorizing Monty Python monologues in the hope that a director in London’s West End will discover them.

Don’t try blogging on your own, friends. I am a trained professional and I am accustomed to bearing the slings and arrows that result from trying to piece together unrelated sentences and worrying about whether any of those sentences end in a preposition.

Time passes. Yada, yada, yada.

And so, as my plane taxied, the stewardess—forgive me, but I was born before being politically correct was a requirement to maintain one’s American citizenship (just in case, I am applying for a green card)—had just finished making her pre-flight safety announcement. Her facial expression suggested that someone should have given her a chew toy.

My tie was all akimbo—that is the wrong usage of the word ‘akimbo,’ but having been a math major, I threw grammar aside simply because I like the word. My seatback was reclined to the level of an all-inclusive Mexican resort lounge position. My tray table was down. My laptop, which was on said tray table, was performing blockchain aerobics. My Bose headphones were pumping out Meatloaf; not as a main course.

If Dylan Thomas was/were (I don’t know which word is the correct usage of the verb.  Was and were are in the past tense, but they are used differently. Was is used in the first person singular and the third person singular (he, she, it). Were is used in the second person singular and plural (you, your, yours) and first and third person plural (we, they)) seated next to me on the plane, Dylan would have said that I was not going gentle (you and I both think that the correct grammar should be ‘gently’) into that good night. However, Sir Thomas wasn’t an English major.

Nor was I. I won’t fault you if you quit reading at this point. I probably should have done all of us a favor and quit writing.

Demurely, I raised my hand and asked the stewardess, cum flight attendant, “Do you mind repeating that bit again about how to buckle the seatbelt? I fly every day, but I never seem to understand the part about inserting part A into part B. Do I put A into B, or do I insert B into A?”

Her head exploded. And that is precisely why I asked the question.

Segue.

You name the industry and I will tell you how bad its customer experience is. Each of us would rather remove our own wisdom teeth rather than call any company’s customer service. Customer experience—healthcare calls it consumerism—is especially inept in healthcare.

When it comes to consumerism or customer experience, what the people who are trying to improve your organization’s customer experience lack in experience, they make up for it with their inexperience.

What would you do if your bank required you to call them every time you wanted to do anything—pay a bill, make a deposit, change your address? You would change banks without batting an eye or worrying about whether the other bank offered free checking. You would not care if the bank was offering a free toaster. You would sacrifice free checking for an easy button.

Healthcare doesn’t offer an easy button.  And to make up for its lack of convenience, nor does it even offer a toaster. Make an appointment, call. Set up a payment plan, call. Talk with a doctor, any doctor, or even someone who plays a doctor on television, call.

However, if you want to make a donation, pay your bill, or learn what time the gift shop opens you can meet those needs online.

Healthcare has created a codependency between the callers and the person answering the calls. Both parties are in agreement that whatever conversation that takes place during the call will be unsatisfactory to both parties. “You don’t want to be calling us, and we don’t want to be talking to you.”

Nobody, or at least almost nobody wants to call your organization. Ever. And how does healthcare address that issue?  Healthcare makes you call. It makes everyone call. Every time.

The World’s Best Customer Experience: The Tuna Paradox

Sometimes you have to get creative and sometimes you just have to manipulate someone to get the level of experience you want. Saturday required me to do both.

I arrived at the diner at 10:30 that morning. I scanned the menu and realized I wasn’t very hungry. The waitress asked for my order. “Toast and tea,” I said.

“We don’t just sell toast,” she replied. I began to count the number of items on the breakfast menu that came with toast—I pointed out that there were 16 of them. “Yes, but you have to order the item. We’re not going to just sell you toast.”

The gauntlet had been tossed rudely at my feet. I could leave or I could accept the challenge. I chose not to leave. I did, however, notice that the lunch menu offered a tuna sandwich that was less expensive than any of the breakfast items that came with toast.

“May I have the tuna sandwich toasted?”

“I suppose we could toast it,” she told me. “What comes on it?” I asked her. “Tomato, lettuce, and sliced pickles.” I began to reel her in. “Okay, let me have it without the pickles.” She made a notation on her pad. I aimed that meant she wasn’t able to simply memorize such a complex order and tell the guy behind the counter. Apparently, this evening’s Mensa meeting would require one less chair.

I eyed the toaster. “Come to think of it, hold the tomato and the lettuce.” “So, you want just the tuna sandwich?”

“Toasted,” I reminded her. “One more thing, can you make the tuna sandwich without the tuna?” Game, set, and match!

While I waited for my toast I also had my most enjoyable customer experience ever although it was not with a firm anyone would ever associate with providing good or even fair customer experience.

I had received my bill from Comcast for cable television. It took less than five minutes to learn that I could subscribe to YouTube TV, watch all of the channels I like to watch, and save beaucoup money. And so I called the Mothership. I was able to speak with someone after only twenty minutes of prompts and being on hold. A digital message informed me that my call was important and that it was so important that Comcast may record it for quality purposes.

Maybe they would learn something.

“How much would it cost if I canceled the cable and just kept the internet?” I kid you not…eleven minutes passed while this purveyor of digital services tried to Devine the answer to my question.

“Do you have a relative who works at a diner?” I asked him. He did not understand my question, and rather than taxing him further, I made the following remark; “You sell two things, cable and internet. I have cable and internet. If you subtract the cost of the cable, what is the price of the internet?” A tuna sandwich without the tuna, I wanted to tell him.

When he couldn’t do the math I hung up the phone and ate my toast. The toast was worth every penny I paid simply to have gotten my way.

And so the great experience to which I had referred was earlier today when I walked into the Comcast office with a box containing my DVR devices and remotes. I canceled my cable service. I felt so good canceling Comcast that I was tempted to resubscribe just for the pleasure of canceling it again.

I should mention that I also learned that I could get internet for less than half of the price Comcast was charging me.

And so I called the Mothership’s customer service line again and I said, “I subscribe to your internet service. What would my monthly bill amount be if I canceled my internet service?”

How To Recognize Awful Experience

I finally had my chromosomes mapped. It should not come as a big surprise when I tell you that I lacked the chromosome for patience and had a duplicate of the chromosome that is most closely associated with cynicism.

Nota bene. I am on my eighth American Airlines flight in the last two weeks. Each of them has been delayed by at least an hour and a half.

Water off a duck’s back. For some, perhaps. But, I’m not your average mild-mannered duck.

And so on the last of my eight flights I pulled out two sheets of paper, one sheet for each side of the plane. Across the top of each page I wrote, “List three things that you would do if you were an executive of American Airlines to improve the flying experience.”

And off they went to Row 1, seats a through C and Row 1, seats D through F. By the start of Row 4 I had received a request for more paper. I hired a small child who was seated across the aisle from me to be my courier. Back and forth he went, dispensing blank sheets of paper and retrieving the completed sheets. On his second trip forward his return trip was delayed.

“What took you so long?” I asked.

“A bunch of people wanted to make videos of their experience,” he told me. “And I had to show someone your age how to Instagram their trip.” (My age?)

I looked up and saw a flight attendant marching posthaste towards me. She was carrying several sheets of paper. The ammonium nitrate was about to hit the oscillating air device.  I gave her my best smile and a wink.  She looked me in the eyes and said, “The captain asked if he was permitted to share his recommendations.”

The wink gets them every time.

Flying.  Bad experience.  ‘Nuff’ said.  The blog could end here.  Healthcare reform could end here.  Neither one will happen.

Most airlines offer two types of seats; first class and no first class – steerage.

First class exists for only one reason—to let the rest of us know that we are not in it.  Airlines hang a shower curtain between first class and coach.  They do this to make it clear to those of us in the bleacher seats that everything beyond the curtain is off limits.  But they do make passengers flying coach walk through first class to get to their seats.  Now each coach passenger has a barometer to measure just how bad their experience is.

“Don’t even think about storing your bag there,” she notifies me.  “This bin is reserved for our first-class passengers!”  Blocking me with her body, the flight attendant turns to the person in seat 2A and asks “May I hang your jacket, sir?  Would you mind if I refill your Crown Royal?  Be sure to leave room for dinner—we’re serving steak and lobster tonight.”  I wished I had purchased the thirty-dollar bag of Gummy Bears.

The bad experiences of coach class are particularly bad simply because first-class exists.  If there were no first class, flying coach would not be so a bad because we all suffer together. Southwest Airlines figured that out.  They do not offer first class.  And despite that, they are always among the highest rated airlines for customer experience.

Healthcare patient and customer experience.  How good was yours?  The scoring is binary —a 1 or a 0.  You either sat in first class or you sat behind the shower curtain.  Did your healthcare experience compare to having surf-and-turf, or did it make you wish you had bought the Gummy Bears?

Bad customer experiences are not insoluble.  Very little is.  For most companies, bad customer experiences are simply a failure of imagination.  For providers, their failure of imagination comes at a high price: poor care management, lost patient acquisition, and poor patient retention. And if that is not a real mess, it will do until the real mess comes along.

Just so you know, none of us likes flying coach.