Four people walk into CMS; two inpatients, one outpatient, and a prospective patient.  One inpatient had a 7.2 HCAHP score, and had his hip replaced at Hospital A and was in the hospital five days. The second inpatient gave birth at Hospital B, had an 8.0 HCAHP score, and was in the hospital for three days.  The outpatient had a colonoscopy.  He did not have an HCAHP score because nobody wanted to know anything about his experience, and the prospective patient was just looking for directions to I-495.

Who had the best experience?  The truth is that nobody knows.

Is it possible that the study of HCAHPs is about as important to patients as the study of ornithology is to birds?

If I were presenting to a hospital team about patient experience as defined by its HCAHPs scores, and I went through the scores one by one, I would expect someone to stop me and say ‘we know all of that.’  “Oh,” I say, “You do?  Then no wonder I can catch up to your knowledge of the scores without having to spend a lot of time studying them.”  The hospital team had invested a lot of time learning about their scores, but that information can be looked up in ten minutes.  Now I am on equal footing when it comes to knowing about their scores, but what do we know about whether those scores mean anything about the experience their patients have?  Is the value in the knowing or in the application?  Knowing the name of something and knowing the something are not the same.

We know that every hospital has patients who leave and who never come back to that hospital, they go somewhere else.  They go elsewhere because they did not have a remarkable experience.  Patients are not supposed to leave and go to another provider.  Leaving means there is a design failure, a design failure with the experience.  And, there is a design failure because the experience was never actually designed, it just sort of evolved.

Which hospital actually believes they create a remarkable experience for every patient every time on every device?  I have learned that if I cannot create something it is because I do not understand it.  Is that why hospitals are unable to create a remarkable patient experience?  Relying solely on HCAHPs will never enable a hospital to create a remarkable experience.  Relying on HCAHPs is like trying to solve a Rubik’s cube while the cube is fighting back.

One can know all of the rules about chess without knowing how to play well.  To me, trying to improve patient experience using only HCAHP scores is like knowing which way the chess pieces move without knowing how to play well.  What we know are the scores, but one patient’s score does not tell us anything about what the patient experienced.  Somebody must ask have we discovered anything about patient experience, or have we only discovered things you can measure in order to discover something about patient experience? 

When I learned that Santa wasn’t real I was actually quite relieved.  For you see I had invented too many different explanations in my mind for how it was possible for him to deliver so many presents to so many children to so many places all in one night.  The number of improbable things that had to happen in order for Santa to be the real solution to how the presents arrived had grown way too complicated.  That same line of thought may apply to thinking that HCAHPs are the solution to understanding patient experience.  Can a patient’s total experience actually be represented by the average of the answers to thirty-two questions? How can a hospital executive test whether their approach to improving patient experience actually improves the experience?  Or is the approach just improving the scores?

The problem with HCAHP scores, with patient experience data, is that one can be so delighted by seeing the data that determining whether the data has real world value takes a back seat.  The data infers that what is being evaluated has precise, measurable answers—the score is 7.23, not 7.22 or 7.24.  The data has precision and certainty.  Individual scores are meaningless if they are used in a way where no conclusions can be made.  Would your organization do anything different if it had received a 7.24 score?  Of course not.

Of all of the possible answers that an individual patient could give to the HCAHPs survey questions, when you look at that patient’s answers, of all of the thousands of scoring combinations that person could have provided, is it not remarkable that that patient would have scored it the exact way they did?  That we cannot predict a patient’s answers means that our experience, our HCAHPs approach is flawed.  If the patient’s answers were predictable one might make a more reasoned argument that the components and mechanics of patient experience were understood.

If you wanted to learn about voodoo, you might expect that the witch doctor knew more about voodoo than anyone else in the village.  However, knowing the most about the problem and having that knowledge result in a solution are different issues.

If you asked individual hospital staff about the confidence they have of their understanding of what makes up patient experience it may range from ninety percent to one percent.  The higher figure would likely come from ‘management’ and the lower figure from people who interact with patients.  That may cause you to raise the question “What is the cause of management’s fantastic faith in how they understand what makes up patient experience?”

It does not matter how remarkable one’s approach is to improving patient experience; if it has not worked it is wrong.  We do not lack the capacity to create a remarkable experience, we lack the imagination.  The difficulty is imagining something you have never seen, something that is different from what has already been tried.

The fact that some people are unable to define the real problem of poor patient experience makes them suspect that there is no real problem beyond what they understand it to be.  The solution lies in being to describe the evidence very carefully without regard to the way you feel it should be. 

The effort to improve patient experience seems to go something like this.  We start with our HCAHP scores.  We do that is because brainwashed us into thinking that every bit of information we need about patient experience can be found in our scores.  We run experiments designed to improve patient experience scores.  We compare the results of the experiments to what we observe.  The scores change—did patient experience change?  If what we observe about patient experience differs from the results of the experiments we ran, the experiments were wrong.  It makes no difference who created the idea or who ran the experiment, if it the outcome does not match reality the experiment was wrong.

Why do we continue along the same path of trying to improve our scores?  I think we do so for the following reason.  If we score in the bottom half of the hospitals it is natural to assume that we need to move to the top half.  Conversely, scoring in the top half is too often taken as a reason to believe that a hospital’s approach to improving patient experience was correct. Their belief in the veracity of their approach is believed in spite of the fact that the results from the surveys vary from patient to patient and month to month.  It is as though their belief in the process today is due to the fact that their prior beliefs were not disproven by their prior HCAHP scores.

What retains patients? If the patient reflects at all he or she will say “I’ve had a bad experience with another provider, but so far I have not had that kind of experience with you.”  These people will stay with you for as long as their remarkable experience continues.

To improve patient experience it does not matter where the ideas come from that are different from yours.  What matters is that they come.  Some people look upon new ideas that are alien to theirs, ideas that seem so outlandish that it seems like they rolled out of bed into a Stephen King novel.

For purposes of this discussion permit me to be Mr. King.  The alien ideas that need to be put in play are the following:

• Patients need to be observed and asked in the context of their experiences
• Many of these experiences occur outside of the hospital
• Experiences are formed on the web, on the phone, and in completing business processes
• These experience matter as much as those measured by HCAHPs
• The only person assessing whether these experiences are remarkable is the patient
• Prospective patients also have many of these experiences
• As long as those experiences are poor those people will never become patients