HCAHPS. The patient is the object of the service.  They are the subject of the experience.

Most health systems focused highly on improving the dogmas of patient experience well before CMS came down from the mountain carrying the stone tablets engraved with the thirty-two statutes.  Trying to channel CMS will not improve your PX score, but it probably won’t make it any worse.

There are two amaranthine rules about Healthcare Customer Experience.

Rule 1: CMS invented the patient experience (PX) rules from whole cloth, without regard to the experiences or expectations of prospective patients, caregivers, family members, referring physicians, and without regard to the experiences that occur outside of the hospital’s four walls–some hospitals may have more that four walls, but the rule still applies.

Rule 2: Consultants cannot change CMS’s definition of PX, but we sure can raise a lot of questions about its shortcomings.

If a health system wrote their annual scores on a whiteboard almost every system’s scores would show improvement year-over-year.  They would also show the degree of improvement decreased year-over-year.  Diminishing marginal improvement.  Once you have fixed the large errors, the low-hanging-fruit, it becomes more and more difficult to gain the next bit of improvement.

Curiously, one question unasked in the patient experience survey could have the biggest impact with regard to how a patient scores their experience. Were you able to fall asleep when you were tired?  How would you feel if you stayed at a hotel, a hotel with excellent amenities, but you could not sleep?  Your survey answers would not reflect the excellent restaurant or the promptness of valet parking.  You would downgrade your experience score of the hotel because you could not sleep.

Several months ago a health system was featured on the cover of one of the trade journals for its innovative approach to improving patient experience.  What did that system do?  It added a screensaver to the desktops at the nurses’ station.  Appearing on the screensaver was the word Quiet.  Maybe Webster’s had dumbed-down the definition of what is and is not innovative.

The difficult part of tweaking out another tenth of a point across any of the thirty-two survey questions is that there are no more easy buttons left to push.

You could add the screensaver.  Or, you could bubble-wrap the Jell-O on the dinner trays to try to keep the noise down.

Or your health system could spend a dollar; one dollar per patient.  And with that dollar purchase two items.  A sleep mask, and a pair of earplugs.

In addition to their diminishing marginal returns, there are those who would suggest that the importance of HCAHPS to patients is of no more importance that the study of ornithology is to birds.  I am one of those people, in part because every health system had been working to improve all of those things well before CMS got involved.

Each of the survey questions, with regard to the calculation of a health system’s score, are of equal weight.  This implies the health system can benefit as much by having cleaner bathrooms as it can from reducing pain.

Now assume your health system had thirty-two patients.  What if each patient scored a different one of the thirty-two questions the lowest—patient 1 scores question one the lowest, patient 2 scores question 2 the lowest, and so on.  Now, if you are a member of your health system’s HCAHPS improvement committee, you are faced with quite the conundrum—what do you fix?  Where do you spend your PX capital to increase your system’s total score?  No matter where you focus your scarce resources, to improve your total score your will always have thirty-one areas that also require your attention.  In short, no matter what you fix, the fix will only meet the needs of a select few.

It is difficult to raise all boats because all of your patients are in different boats.

So, what can you do to raise everyone’s experience?  Is there a way to raise everyone’s experience all at once, or do you have to do it patient by patient?

There is indeed.  To raise everyone’s experience the first thing you must do is to define who belongs to the group everyone.  Why not agree that the group everyone consists of every one?  All of the health system’s stakeholders who have an experience with the health system.  Inpatients, outpatients, former patients, consumers, family members, and physicians.

Now that we know the answer to WHO has the experiences, we should answer the question WHAT.  What are those experiences?  Find out which experiences are the most common among your stakeholders, and which experiences have the greatest impact on their satisfaction.  That way to do that is very complex—you ask them and you observe them.

There are those who believe if a patient reports that the nurse in radiology is a grouch, writing checks to firms like Studer will improve the overall experience.  If you really want to raise all boats, ask yourself before you write that check what percentage of your stakeholders will actually interact with that specific nurse in radiology.

Improving WHO and WHAT is underway.  Let us address the question of WHERE.  Begin at the beginning, when your stakeholders have their first experience with your health system.  If you start fixing things at the wrong end, hundreds, perhaps thousands of your stakeholders will have already rated their satisfaction with their feet; they will have left your system without ever having had the chance to see how well you fixed the parts of the experience they never experienced.

All of your stakeholders, every single one of them will experience your health system before they ever set foot inside one of its facilities.  And based on their satisfaction with their first experience they will decide whether they will have another experience.  Their satisfaction with your health system is cumulative—Experience A + Experience B + Experience C, and so forth.  A bad initial experience taints the whole experience.  I am sorry there was a fly in your salad, but how was the entrée?

Seventy to eighty percent of your stakeholders will visit seven websites before they try to access your health system by phone, and half of those stakeholders are not currently your patients—they are consumers, consumers shopping for healthcare.  Assuming your health system’s website was one of those seven sites, what kind of experience did your stakeholders have?  Unless the reason for their visit was to pay their bill, they had a poor experience.  That means your health system is oh-for-one. (Fortunately, almost every health system’s website offers nothing more than yours.)

I saw a television commercial advertisement for a large Philadelphia health system.  Its message was, “To schedule an appointment visit us online.”  Guess what?  I visited.  The word schedule did not appear on the homepage.  I clicked on the patient link.  It did not appear there either.  I entered the term in their search box.  No luck there either. There was the ubiquitous link to pay your bill.  I would bet dollars to doughnuts ninety-eight percent of health systems are no better.

The reason stakeholders go to your website is because they do not want to have to call your health system any more than they want to call Verizon.  Did you know that twenty-five percent of the people who call a company (your health system is a company) are likely to change to another company simply because they had to call?

What do we know so far?  If you measure the experience by whether it provided value to a stakeholder, the online experience was of no value.  And how good was their phone experience? Not much better, but don’t take my word for it. Go listen to some calls.  The average person has to call almost three times to complete a single activity.

If a person has a bad online experience and a bad phone experience, what is the likelihood they will ever go to your website again? If they had to call three times to get an appointment, are they really going to care that you hired someone to coach the nurse in radiology, or will they have purchased their healthcare from someone else?

None of this is difficult unless you don’t think you have a problem.  You can try this approach, or you can install the screensaver, buy the earplugs and sleep mask, and hope people who visit your website pay their bill.  Who knows, maybe your HCAHPS scores will increase.