Dear CMS: How To Innovate Patient Experience

A store in Colorado was going out of business and was selling everything including its light fixtures.  There was a large table, and the table was covered with deeply discounted purses.  The table was surrounded by a school of women attacking the purses in a way that reminded me of how a school of piranha would dismember a wild boar.

Above the table, attached to the ceiling was my light fixture; unlit.  I elbowed my way past the women and placed a chair smackdab in the middle of the table.  I stood on the chair, reached up, found the wires, and sliced through them with a quick snip.  A bright purple flash of light raced across the ceiling and the air smelled of burnt oxygen.

Nonplussed, I yanked down the fixture and drove home whereupon I tuned into the local news channel to see if needed to turn myself in to the police.  Cutting the electrical wires had burned a new hole in my wire cutters.

I have a pretty good tool collection, and because of my mechanical ineptitude most of my tools are just as shiny as the day I bought them.  I bought an entire set of crescent wrenches because nuts and bolts come in a million different sizes; metric and nonmetric.  A different wrench for every problem. They are hung neatly, by size, on a peg board in my workshop.

I also have a pair of vice grips, and the great thing about the vice grips is that it was designed to be adjustable.  That they are adjustable allows me to use one tool to solve every problem instead of having to use a different tool for each problem.  We will come back to this.

Walk through this with me for a minute.  I had a dinner party.  Some of the guests got lost on their way there, some got lost on their way home.

Let’s say there were a hundred guests and ten servers.  After the party, I asked a friend who did not know anything about the guests or the servers, and who did not attend the party, to come up with a series of questions and ask the guests about their experience at the party and their experiences with the wait-staff.  I also asked him to do the same thing with the wait-staff.

I read all of the answers, made a few adjustments, and threw another dinner party for a totally different group of people and a different group of servers, and after the party I got my neighbor to ask his questions again.

And how would you expect the second set of scores to compare to the first set of scores?  There are several reasons why I would not expect much variation between the two sets of scores.  At each party the wait-staff mixed randomly among the guests and meet various needs of each guest.  The backgrounds of the guests at each party were quite varied.  And neither the guests nor the wait-staff were asked before the party what their expectations were and what would constitute a good experience.

Now imagine there are several thousand of these parties going on repeatedly across the country, each with different guests and different wait-staff.  My neighbor queries everyone after every party, and the party hosts make adjustments based on the answers.

So my question is, how long does it take until everyone at every party reports back to my neighbor that their experiences were perfect?

It will never be perfect, in part because the players keep changing, and because nobody ever asked them ahead of time what would make for a good experience.

Multiply that analogy by the square root of two and you have healthcare and CMS.

Dear CMS.

The players keep changing and nobody ever asked them what made for a good experience.  Trying to improve everyone’s experiences, based on a survey that lacks as many questions as it asks. Game theory would label this process as a “lose-lose situation,” a situation in which neither party benefits from the outcome. It is the design of the process that makes it impossible for either side to declare victory.  The provider’s best efforts fail because their approach ignores:

  • most of a person’s experiences
  • most if its stakeholders
  • where most experiences occur

The stakeholders (outpatients, inpatients, former patients, consumers, and physicians) lose because CMS’s approach ignores the same three things.  Provider efforts are focused on a crescent-wrench solution—a different wrench for each patient—figure out what went wrong with this person’s experience, and that person’s experience, and the next person’s.  And at no point in time did the provider ask a single stakeholder what factors make for a good experience.

Year after year providers and patients do the same patient experience dance, and the dance always yields no net gain for either party.  And the reason is because what is important to CMS and what is important to a provider’s stakeholders are mutually exclusive.  Oil and water.

Patient Experience innovation is not a screen saver showing the word “Quiet”.  There is a very simple innovative solution.

  • Account for all of the stakeholders
  • Account for all of the places where they experience the health system
  • Define the access and engagement requirements that comprise a person’s experiences

Then use all of that information to design a process that will yield the best possible experiences for all possible stakeholder interactions.

A vice grip.

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