I was reminded of the adage, “What do you call a thousand consultants at the bottom of the ocean?” A good start.  I thought I would start today by being self-deprecating in case it may lead you to thinking of me as being winsome.

What do you call HCAHPs?  A good start?  A start?  Regarding patients and managing their experiences, we are not at the end, we are not at the beginning of the end, nor are we at the end of the beginning—somewhat of a paraphrase of Mr. Churchill.  He also said, “Dogs look up at us, cats look down on us, and pigs look us in the eye…I think I will have a pig.”

We do not know what we do not know.  The funny thing about HCAHPs is almost every hospital would be making the same effort to improve these metrics even if HCAHPs did not exist.  Why?  Because it is simply good business.

The funny thing, the unfortunate thing about applying metrics to business goals is our tendency to hit what we aim for.  In most cases this is lipstick on a leprechaun—achieving the metric has little value other that stating that you hit what you set out to do, because the improvement target was so exiguous as to be inconsequential.

I believe this is the case with how many health systems approach improving their HCAHPs scores.  Let us visit together, your favorite and mine, the hospital, Our Lady of the CMS Anathema.

Thirty-two survey questions.  Thirty-two responses calculated to the hundredth percentile. For the poly-sci majors this may not mean much, but to those of us who labored in the sciences, or anything above mathematics for librarians, there may be something of note. 

For example, let us assume that 1,000 patients completed the survey, and for the question about the cleanliness of bathrooms your hospital scored a 6.28.  the internal HCAHPs improvement committee meets, and they decide that the hospital needs an action plan to raise its clean bathroom score—as best as those patients can recall from seven months ago about whether their bathroom was always clean, usually clean, or if its cleanliness reminded them of the cleanliness of an Amtrak rest room in Manhattan—from a score of—6.28 to a whopping 6.31.  Using our fingers and toes to do the math, don’t forget to carry the one; that difference equates to 30 cleaner bathrooms per one thousand.  A herculean feat? I bet that most patients cannot remember what floor they were bivaqued on seven months ago let alone the cleanliness of their bathroom.

So what do we have? We have an action plan for thirty patients. Add that to the action plan for improving our scores on the other 31 CMS questions and what do we have?  We have an action plan for looking like we are doing something.  We don’t know where we are going but we are making really good time.

Here is my point.  To improve some of the HCAHPs scores requires a mix of art and science—pain management. Hospitals would be working their darndest to improve this metric even if CMS did not exist.

However, and this is my real point, is there a hospital in the US that should be penalized for having unclean bathrooms and too much noise?  Of course not.

No management committee worth its salt—or its salary—should be developing an action plan to have ten percent cleaner bathrooms by the start of 2014.  That is absurd.  Everyone reading this has taken their family on some form of road trip.  You wind up in “Who the heck knows where I am Iowa”, you pull off the highway because you saw a big blue sign indicating that the next exit has Bubba Joe’s Motel, disco, and taxidermy, last rest stop until you reach Singapore.  You have driven thirteen hundred miles since your last stop, your prepubescent son now needs to shave, and you figure “What the heck?”

You pay Anthony Perkins for two rooms—younger readers should Google the movie Psycho, you check out the bathrooms and decide it is safe to shower.  Why is it safe?  On the faux granite counter are ampoules Of Bubba Joe’s Agent Orange skin defoliant, shampoo, and conditioner.  The end of the toilet paper roll has an origami fold, shaped like an architectural model of the Our Lady of the CMS Anathema hospital.  A paper band is wrapped around the lid of the toilet, and the shower plug is in the closed position.

While Bubba Joe’s is not the Ritz, the evidence in the bathroom shows it has been cleaned.  How then if Bubba Joe can clean his bathrooms can a hospital score at the HCAHPs median for clean bathrooms?  If the hospital’s CEO announced over the intercom, “A patient survey indicated that one of our bathrooms was not cleaned. I am coming down in an hour to check it,” you have to believe that all of the bathrooms would be recleaned within the hour. (Apparently recleaned is not a word in Office; it is now.)

This is a freebee.  Clean the bathrooms.  If some Podunk hotel can clean its bathrooms one hundred percent of the time, so can a hospital. Do not set your goals to improve your rating of the cleanliness of bathrooms by 10%. Imagine how the Four Seasons Hotel would react if it noticed that one-third of its bathrooms failed to get a satisfactory rating—that problem would be solved in less than a week.  Set your goal for cleaning all bathrooms every day.

Now, here is the ten-cent freebee.

I am in my bedroom reading. The children are asleep. My wife is watching a reality show on Bravo, Anorexic Albanians making a mirepoix for one thousand refugees in a thimble.  I ask her to turn down the volume because I am reading the complete works of Shakespeare engraved on the side of a single grain of rice.

We get to the point that if she drops the volume of her television show again she will not be able to hear her show and she will not know how to make the mirepoix.  She has done everything she can do to cut the noise to a point where she can still here her show and to where I will not be inconvenienced. If she drops it any more there is no value to her.  Jump back with me now to HCAHPs and the futility of pushing water uphill.  What if there was something I could do that would enable my wife to hear her show and that would allow me to read me book?

What to do.  What to do indeed.  The way hospitals look at the noise problem is to do all they can to make sure that the noise is as small as possible.  Any other marginal improvements would be like squeezing blood from a stone. Ergo. 

Think out of the box.  Most people believe they are already thinking out-of-the-box. You and I both know that while most people claim to be out of the box, their out-of-the-boxness cannot be attributed to thinking, it has much more to do with having followed the lemmings. If everyone is out of the box, all that has happened is that the box has moved.

Change your perspective, if just for a moment.  If your hospital has done everything it can to reduce noise, you have wrapped foam cushions from the Space Shuttle around the salt-free Jell-O you serve at lunch to reduce the extraneous noise, and that has not solved the problem, rethink the solution.

If you cannot reduce the noise your patients hear, maybe you can reduce the noise heard by your patients.

Ten cents. One dime. 

If you have ever flown business or first class to anywhere outside of “God Bless the USA”, you get to your seat, the stewardess or flight attendant—I do not claim to know the PC term for the job—but if you are flying in business class or first class—presents you with a mimosa, and a dopp-kit.  The dopp-kit, which cost them a dime, contains a pair of socks, a sleeper mask, and a pair of earplugs. 

If there was ever a barometer for poor customer experience the airline industry is front and center. “We would like to thank you for flying with us…but we won’t.”  Hospitals. We would like to thank you for having your hip replaced with us…but we don’t.

Once the hospital has done all it can to alleviate the noise, their next step is to think out-of-the-box.  What if the hospital gave patients a way to cut the noise from their end?  Hospitals cannot put noise buffers on the Jell-O.

Why not give patients ear plugs, a sleeper mask, and a pair of socks? Even if it does not solve the entire problem it may lead patients to believe you are trying to help. If you want to be fancy consider a pair of noise cancelling headphones.