One of the strange things about tsunamis is that the most damage is always the result of the second wave, a wave that catches survivors of the first wave by surprise.

If I was a healthcare executive I would have spotters positioned along the beaches looking for wave number two.  Instead, many appear to be taking on Mad Magazine’s Alfred E. Neuman’s “What—Me Worry?” attitude.

And here’s why.  Ask to see a copy of your health system’s strategic plan.  That may be naiveté on my part, but let us pretend that such a document exists.  In it you should find a section about where the industry is headed, how that effects your organization, and what your organization is going to do to either take advantage of it or to defend itself from it.  I’ll give you a few moments to read those sections…

You couldn’t find that part of the plan, could you?  If you went back five years you wouldn’t have any more luck finding that same information in your systems 2010 strategic plan.  Your 2010 strategic plan should have mentioned something about possible threats to your business, possible threats about continuing to remain relevant.  And included in the discussion about threats should have been a discussion about consumerism—healthcare’s four-letter word.

I challenge you to name a single, provider-driven, impactful innovation to the business of healthcare in the last fifty years. An innovation created by providers to improve their business model.  Can anyone recall leaving a strategy meeting and thinking, “Wow, that should shake things up.”

Large retailers held those meetings five years ago, and they came out of their meetings with a plan to bring three things to healthcare; disruption, efficiency, and cost management.  Those companies include Wal-Mart, CVS, Whole Foods and Target.  And how have providers reacted?  They have not.

Now for the bad news.  Those same organizations have held more meetings, and what is about to hit the streets is wave two of the tsunami.  And that wave will deliver even greater disruption, more efficiency, and even better cost management.

I don’t know the figures for the number of patients seen by CVS, but I am willing to bet that their growth rate and acquisition of new patients is worthy of envy.  And since more people are not getting ill, those patients must be coming from somewhere.  Retailers are gaining share in a market of excess capacity. The Minute Clinic model has demonstrated that consumers are brand-agnostic purchase unless patients are seeking specialized care.

Is there a better brand name on the planet?  Minute Clinic—service in a minute. And they compete for patients against organizations that have Eight-Week Clinics—service when we have an opening.

CVS did not have to build a single new facility to take millions patients from providers and PCPs; they simply reallocated floor space.  Heck, they hardly even advertise, and millions of people gladly drive one or two miles for on-demand healthcare.

So, if I am an executive at CVS or Walgreens, what is the next great question they should be asking themselves?  I think it is this—“How can we deliver more care to more people without requiring people to come to our stores?”  That is wave number two.

The other issue overlooked by provider executives is that 75% of people are very loyal to their retailers.  Their loyalty to organizations from which they purchase their medications is even higher because their healthcare insurance is tied to a specific drug retailer.

Consider this for a moment.  People think of Uber as a taxi service.  Uber’s valuation exceeds $40 billion dollars.  And guess what?  Uber, the taxi service, does not own a single car.  That same taxi service does not employ a single driver.  It does not care whether gas prices go up or down because it does not pay for a single gallon of gas.  It simply puts drivers and passengers together and lets them sort out the market.

Hotels.com does not own a single hotel.  OpenTable does not own a single restaurant.  What those organizations own are ideas, ideas that put buyers and sellers together easily and in real time.

And while firms like CVS are disrupting the traditional way of purchasing healthcare, health system executives still think of the term customer as another one of those four-letter words.  Note to health system executives: do not concern yourselves with how many letters are in the word, concern yourselves with how to embrace the word.

Every health system that added valet parking did so for one reason—to attract and retain patients.  Upgrading your cafeteria and adding a valet service are not examples of innovating your business model.

Beefing up your marketing department will not enable your health system to compete against the second wave.  Most health systems cannot even tell you whether marketing’s efforts added a single patient to their system last year.

The time to innovate was last year, and the year before, and so on.  My immediate advice to provider executives would be to do one of two things; hold an innovation retreat and do not let anyone leave until everyone in the room thinks Wow, that should shake things up.  Or, grab your Speedo and some suntan lotion, and wait for the second wave.

Some things about the healthcare provider business model continue to stupefy me, things I cannot wrap my brain around.

One of those things is their strategy.  When I think of business strategies I think of the word plan—what are we going to do, how are we going to do it, who is going to do it?  Most strategic plans lack one thing, a plan.

Healthcare is not an industry where nothing is going on.  Until recently, there were only three major forces to disrupt the provider business model; the government, the payers, and the pharmaceutical firms.  Providers would write their plans on an Etch-A-Sketch because nobody knew exactly what those forces would do to them.  Strategies, for the most part, were designed to react to disruptions brought about by organizations much larger than they were.  Those three forces made the rules, controlled the purse strings, and controlled the medications. The forces were strong enough year in and year out to cause provider business strategies to be reactive.

During the last twenty years providers disrupted their own business strategy, and they did so to their detriment.  Providers opened the door to specialty competitors and clinics popped up everywhere, siphoning away patients and revenues.  Patients and revenues that providers have yet to recapture.

Over the last decade provider strategies were neither innovative nor disruptive.  Planning sessions focused on what would CMS do; what would payers do to hurt us; what are the pharmaceutical firms up to?  Should we be hiring, or should we focus on cutting costs?

Then came Obama care; the Affordable Care Act.  And provider penalties.  And a few hundred million dollars for an EMR—brand new hospital wings could have been built for what providers spent on 1s and 0s.  The payers bemoaned the impact of the ACA on their business like Brer Rabbit saying, “Please don’t throw me in the briar patch.”  Provider strategies focused on maximizing the Meaningful Use rebate—not much of strategy, but providers weren’t calling the shots, they were reacting.  Some providers bought primary care practices while others got rid of them.

And while providers were focused on the shell game of payers, pharmaceutical firms, and the government their entire business model changed.

And it changed without them knowing about it or reacting to it. It almost seemed like the provider executives were not copied on the email.

And what changed; what was overlooked?  By the end of 2014 there were 800 Minute Clinics. By 2017 it is forecasted that there will be 2,800 walk-in medical clinics.  Walk-in clinic revenues in 2013 were estimated to have exceeded $800 million.  Then there are the thousands of Quest Diagnostic clinics.  That is why the waiting areas in the hospital labs are so small; they no longer need a lot of seats.  More revenues gone, repeatable revenues.

So, let’s backtrack to the idea of the provider business strategy, the plan.  The plan to do what?  Retail healthcare is not coming—that is not good news.  It is here, it has been here, and the growth and patient loyalty of these services are phenomenal.  As is the revenue loss for providers.

So, does consumerism fit in the provider business strategy?  It should be the provider business strategy. Is it part of the provider business strategy?  Most likely it is not.  That begs the question “Why not?”

Should large providers open dozens of store-fronts?

I look at the situation this way. If you visit Quest or the Minute Clinic you see chairs.  And in those chairs you see people.  You can see chairs with people in them at the hospital.  There is one very big difference if you happen to be a provider executive.  The people in the chairs at the Minute Clinic and at Quest are consumers.  They are people with no appointment.  Consumers who are in the process of purchasing healthcare, who are in the process of purchasing it the easy way, and who are in the process of building a loyalty with their new healthcare providers.  These people will continue to purchase additional services until they are told they need a service beyond the capability of the clinics.

The importance of the chairs is what they represent.  Hospital chairs represent patients. Minute Clinic chairs represent a way to convert potential patients—consumers—into new patients.  Walked in a consumer walked out a patient. A very repeatable process, and one their consumers repeat again and again.

Hospitals do not have a way to easily attract and capture new patients—consumers.  Neither do their clinics—no walk-ins allowed.  Hospitals only have a way to fill a time slot weeks or months away with a scheduled patient.

So, until providers get into retail medicine the way the average consumer understands retail medicine, what can they do strategically to disrupt their business model in a way that is beneficial to them?

• Phase 1—Hire floaters. Hire someone who could see a patient who wanted to be seen.  Wow, that was easy.  You may think that would be expensive because doctors are expensive.  Doctors who do not see patients eight hours a day are expensive.  However, if the value of an average patient is worth $200,000, how many patients a week does the floater need to see to make it cost effective?
• Phase 2—UberMD. We both know scheduling, especially scheduling new patients, can be a disaster (for the patient).  They want to be seen now, but you do not have an opening in the next six weeks.  From the patient’s perspective, that equates to zero access.  I called the children’s hospital of a large New England health system asking to see an orthopedic surgeon. The first available appointment was in six weeks.  That same health system had more than a hundred orthopedists on staff, but since those doctors were not at children’s my request hit a wall.

What if this type of solution was available?  Take the Uber concept, multiply it by negative one, and out comes UberMD. Instead of alerting all of the Uber drivers in my area that I need a ride and sending one to me, UberMD alerts all of the orthopedists in the health system and lets them know I need an appointment.  The health system’s doctors reply to my service request and I have an appointment much sooner than six weeks.

Patient capture. Patient satisfaction.  On demand access.

I try to learn something every day, and yesterday was no different. I had been a long day. Multiple train rides, miles of walking, and I was tired. I reclined the seat, put on my headphones, closed my eyes and drifted off into a half-lucid state as I listened to Les Misérables.  Apparently, I was doing more than listening.

I had somehow forgotten I was on a train; on a train surrounded by other weary travelers.  One of my favorite Les Mis songs is Bring Him Home.  I like to sing along with it, and I like to sing loudly.  And so I did. I had also forgotten that just because you cannot hear others when you are wearing headphones does not mean that they cannot hear you.

The applause is what caused me to open my eyes. I glanced around to learn what had caused the commotion, and to my embarrassment discovered I needed to look no further than my seat.

So that was my day.

According to CMS the average American spent almost $10,000 on healthcare in 2014.  People, you and I, are having to pay a higher percentage of that amount from our own wallets.

That means we are more selective about where we choose to spend our healthcare dollars.

I spoke recently with a health system executive about what the provider business model will look like in two to three years.  During our meeting I shared the following information about my family’s consumption of healthcare over the last twelve months:

• 17 visits to the Minute Clinic
• 3 visits to an urgent care facility
• 5 visits to specialists
• 0 visits to a primary care provider
• 0 visits to a hospital

We were selective, and we selected to purchase our healthcare services to the exclusion of providers.

The U.S. healthcare system is unbelievably good.  This week Children’s Hospital of Philadelphia announced that it had completed the very first double hand transplant.  Amazing!  One of the things I took away from their announcement was that it was the very first.  I am not knowledgeable enough to know whether it being the first had to do with the lack of demand for this type of procedure.

Healthcare providers are very good at delivering services that are firsts, at figuring out how to successfully do things others did not think could be done.  Things 99.9% of people will never need.

Healthcare providers are proving themselves to be very poor at delivering services that are lasts, services that 99.9% of people need.  Services that people need this year and that they will need next year.

She replied rather emphatically, “We are not in that business.”  Her comment was our biggest point of agreement.  If that is where people are spending their healthcare dollars, wouldn’t it make sense to figure out how be in that business?

People—patients—want access and convenience.

Wayne Gretzky (think very good ice hockey player), when asked why he was so good replied he learned to skate to where the puck was going to be, not where it has been.

While most providers are debating whether ice hockey is even a sport, their patients and prospective patients a lacing up their skates.

Yesterday another provider executive asked me what surprises me the most about healthcare.  I said I did not understand why executives from the VA, UHS, Tenet, and CHS were not standing outside of Tandy’s Fort Worth headquarters gobbling up Radio Shack stores.

Healthcare executives who stand by the adage, “We don’t have customers, we have patients,” may soon find themselves in the position of having neither.  To be successful, it helps to sell what people are buying. It also helps to sell it in the manner they like to buy it and when they like to buy it.

I think that may be why children don’t set up lemonade stands in Minnesota in January.

The two vehicles were traveling at the same rate of speed.  Their speed relative to each other was zero.  The person manning the control of the second vehicle accelerated slowly.  Not only did he have to close the distance to complete the docking procedure, he had to ensure that his craft didn’t come in too high or too low, and that his pitch and yawl were in alignment with the airlock of the larger craft, just forward of the massive carbon-fiber wing.  A few sets of eyes from the pressurized cabin peered anxiously through the reinforced portal.  If all went well, and the two craft were aligned properly, the complex procedure would be completed in a single adroit maneuver, and the occupants would be able to transfer safely from one vehicle to the other.  It took seventeen minutes to dock the two craft.

If you didn’t know better you might have been thinking I was describing the International Space Station and the Space Shuttle.  In reality, it wasn’t nearly so glamorous; just my USAIR flight and the gate jet-way.  The jet-way driver’s efforts resembled those of a goat learning to operate a chainsaw.  It occurred to me that the driver must have had to pass a series of interviews to land the job.  It made me seriously question the qualifications of all of the applicants who were not offered the job.

If you happen to be a customer experience consultant and writer, and you happen to fly, the implications of putting the two together make your head want to explode—there are just too many things in play.

A few hours prior to the Shuttle docking, was the boarding process for USAIR.  The airline has roughly 917 different levels of status for boarding passengers; special needs, wheel chair passengers, military, first class.  Then there are those who have precious metal status; platinum, gold, and silver.  Followed by the gemstone passengers; diamond, ruby, emerald, and so forth.  Passengers of status enter through one of the cattle gates; passengers with lower status board through a lesser cattle gate, a gate separated by a thin nylon cord.  The cord is there to separate valued customers from those whose status is not worthy of boarding using the lane used by the cool people. (Delta even lays a special bathmat on the ground upon which their SkyMiles Plus passengers are allowed to walk.)

Once they boarded the precious metals people, and the passengers who have a USAIR credit card, and the people who paid an additional thirty-five dollars to board sooner than they otherwise would have—about thirty seconds sooner; you can’t make this stuff up, but somebody obviously did—the gate agent was ready to board the remaining wretched refuse.  I think the level of status printed on my boarding pass indicated my status level was Chalk.  Chalk status did not entitle me to a flotation device or a drop-down oxygen mask.

Did I mention I hate the flying experience?  Airlines used to market their service using chipper, customer-friendly slogans; ‘We love to fly and it shows,’ “Fly the friendly skies,’ ‘Delta is ready when you are.’

If there were truth in advertising their slogan would be, “You hate to fly and we hate having to fly you.”

Many health systems try to skirt the issue by saying they do not have customers; they have patients. Using that attitude, pretty soon they will have neither.

Over the last few months a few readers wrote asking about a post of mine regarding speaking in public.

For those who get nervous about speaking in public, let’s recognize that unless you are being filmed for the Discovery Channel’s television show Life Below Zero, you speak in public every day—to your friends, family, and colleagues.  They listen, you speak.  You don’t read from notes; you don’t pull out a PowerPoint deck.  Rarely do they heckle.  That was easy, wasn’t it?

So what is the difference between what you do every day, speaking in public, and public speaking? Maybe it comes down to the adage about it being best to keep quiet and have people wonder if you are a fool than to speak and remove all doubt.

Unfortunately, you have probably sat through more poor presentations than good ones.  Within thirty seconds of the start of a meeting or a speech, I have already decided whether I am willing to invest another thirty seconds.  The good news is I do not think I ever saw a presentation where the material presented was flawed.

It may have been uninteresting. It may have been gnaw-your-arm-off dull, or difficult to hear, or too much material, or too tiny to see.  But more often than not the material is correct, so let’s not worry about fixing that part.

So everything else that makes a presentation a success or a failure comes down to you; and those things can be fixed provided you know what they are.  But the first thing we ought to address is the fact that most presenters telegraph fear just like a gazelle wading into the watering hole in the Serengeti—Hey, look at me. I know you will eat me alive.

One way to deal with your fear is to become a regular at the nearest karaoke bar, try to be entertaining—unless you are delivering a briefing to the Joint Chiefs in the Situation Room.  Worst case, your goal should be for people in the audience to conclude that you or your material or both were interesting or entertaining.  Your presentation will be no worse than your singing performance, and if you can get comfortable singing in front of a room full of people doing tequila shots, or at least you can survive your rendition of Queen’s Bohemian Rhapsody, your presentation in front of people who want you to do well will be much improved.

So, you are now feeling more confident, and you look out from the front of the room and everyone is looking back at you.  You need an opening, and it needs to be good.  Every pair of eyes is watching you, waiting for you to win them over.  Try starting with, “It’s okay to record this and to take pictures.  I’ll be doing the same thing.”  Then pull out your phone and tell everyone, “Lean in.”  And take their picture.

If you cannot get over the fact that everyone is looking at you, you will wind up looking at your feet to avoid eye contact; and once you do that you lose.  When you look at your feet, your head is pointing to the floor, and when you speak you are speaking to the floor.  If someone needs to be looking at your feet, why not get your audience to be the ones doing the looking?  But you have to give them a reason to look.  That is where the socks come in.  Find a pair of great, colorful, patterned socks.  Then pull up one leg of your pants and tell the crowd, “My wife told me that if I was going to wear these socks that I’d better deliver one heck of a good talk.” (This technique may not be as effective for women.)

So, you are now feeling more confident, you are not looking at your feet—they are—now what?  You’ve got to say something—and this is your last make or break moment.  This is where most people fail.  Your audience cannot remember what they ate for breakfast, and here you are ready to give them hundreds of unmemorable facts, typed in 8-point font, on dozens and dozens of PowerPoint pages.  And how will you deliver those facts? If you are like most presenters, you will turn your back to the audience and you will begin to read.  Do that and you have just lost.  You are now speaking to a wall.  Nobody can hear what you are reading.  Nobody can see what you are reading.   And if you turn around quickly, you will see everyone looking at their watches or texting away on their phones.

When I give a presentation I make I bold assumption—everyone in the room can read.  If they can read and I can read then one of us doesn’t need to be there; one of us is superfluous.  You do not want to read and you do not want them to read.  That is another reason I never provide handouts until after the presentation.  If you give them a handout, they will skim through it before you’ve even told them about your socks.  Then they will tune you out and pull out their phones and you will have lost them

The best way to avoid that mistake is to put ideas on your slides instead of words—they cannot read ideas, but neither can you.  I like to use pictures instead of bullet points.  Bullet points, if they are any good, lead people to taking notes, and if they are taking notes they are not paying attention to you.  I People do not take notes at the symphony, they do not take notes when you are talking.  There will not be a test at the end of the presentation.

Now that you have addressed everything that could go wrong start talking.  You’ve thwarted the issues of public speaking, and are now simply speaking in public—something you know how to do.  Tell them why the ideas are important to your topic, and give them an easy phrase they can use to remember each idea.  The phrase should be more memorable than what they had for breakfast.  And if at any point in your presentation you feel like you are losing control of yourself or the audience, you can threaten to start signing.

At one time the single word Lubyanka was enough to bring normal Russians to their knees in terror.  Lubyanka is known best for being the headquarters of the Soviet secret police.  The basement of Lubyanka housed a prison which contained one hundred and eleven cells, cells used to hold and interrogate political prisoners during Russia’s purge.

Tea was provided to the prisoners twice each day.  Each prisoner would place their teapot outside the cell. A prisoner, carrying a pail filled with tea, would pour tea from the pail into the teapot.

Tea spilled on to the floor.  The prisoner who poured the tea would clean the spilt tea with a rag.

Lubyanka’s prison operated for twenty-seven years.  Tea was served to the one hundred and eleven cells and spilled in front of each cell twice a day, seven hundred and thirty times a year.

Two million, one hundred eighty eight thousand spills.  The same number of cleanups.

Someone somewhere made the decision that it was easier or cheaper to spill the tea and sop it up 2,188,000 times than it was to make pails with spouts on them.

What are the pails in your company?  What dumb, wasteful, redundant activities and processes have been left unchanged?

The most obvious one for most companies is call centers.

People must believe it easier to take 2,188,000 calls each year about its bills than it is to fix the bills.  It is easier to take 2,188,000 calls each year about the bills than it is to eliminate bills.  The same argument can be applied to most of the other broken business processes that cause customers to call.

And do you know where the fallacy in the argument is?  The fallacy comes from the erroneous belief that by having a call center, by answering calls you are actually providing your customers a service.  Most customers never want to call any company they do business with.  Simply being forced to call means one of every four callers considers finding a new company to call.

Answering customer calls can hardly be described as offering a service. All you are doing is wiping up spilt tea.  If you want to really provide your customers with a service, fix whatever is making them call.

I have a knack for complicating simple things, but the voices in my head tell me that is better than simplifying complicated things.  Either way, I appreciate those of you who continue to play along.  Just remember, if you choose to dine with the devil it is best to use a long spoon.

You’ve probably figured out that I am never going to be asked to substitute host any of the home improvement shows.  I wasn’t blessed with a mechanical mind, and I have the attention span bordering on the half-life of a gnat.

Projects involving me and the house have a way of taking on a life of their own.  It’s not the big projects that get me in over my head—that’s why God invented phones, so we can outsource—it’s the little ones, those fifteen minute jobs meant to be accomplished during half-time, between pizza slices.

Case in point—touching up the trim.  Can, brush, paint can opener tool (screwdriver).  Head to the basement where all the leftover paint is stored.  You know exactly where I mean, yours is probably in the same place.  Directions:  grab the can with the dry white paint stuck to the side, open it, give a quick stir with the screwdriver, apply paint, and affix the lid using the other end of the screwdriver.  Back in the chair before the microwave beeps.

That’s how it should have worked.  It doesn’t, does it?  For some reason, you get extra motivated, figure you’ll go for the bonus points, and take a quick spin around the house, dabbing the trim paint on any damaged surface—window and doorframes, baseboards, stair spindles, and other white “things”.  Those of us who are innovators even go so far as to paint over finger prints, crayon marks, and things which otherwise simply needed a wipe down with 409.

This is when it happens, just as you reach for that slice of pizza.  “What are all of those white spots all over the house?”  She asks—you determine who your she is, or, I can let you borrow mine.  You explain that it looks like that simply because the paint is still wet—good response.  To which she tells you the paint is dry—a better response.

“Why is the other paint shiny, and the spots are flat?”

You pause.  I pause, like when I’m trying to come up with a good bluff in Trivial Pursuit.  She knows the look.  She sees my bluff and raises the ante.  Thirty minutes later the game I’m watching is a distant memory.  I’ve returned from the paint store.  I am moving furniture, placing drop cloths, raising ladders, filling paint trays, all under the supervision of my personal chimera.  My fifteen-minute exercise has resulted in a multi-weekend amercement.

This is what usually happens when the plan isn’t tested or isn’t validated.  My plan was to be done by the end of halftime.  Poor planning often results in a lot of rework.  There’s a saying something along the lines of it takes twice as long to do something over as it does to do it right the first time—the DIRT-FIT rule.  And costs twice as much.  Can you really afford either of those outcomes?

Can you really afford to scrimp by not having a patient experience plan?  Ask to see a copy of it. I’ll bet you my neighbor’s BMW that there is no plan.  Seventy-five percent of health systems spend less than a hundred thousand dollars a year to improve PX.  If you don’t come out of the gate correctly, it will be impossible to get better.

If that does not work we will always have Paris.

Not long after graduating with my MBA from Vanderbilt, I returned to Vandy to interview the soon to be, freshly-minted MBAs for employment.  Accompanying me on the trip, was my adult supervisor; my chaperon; the Vice President of human resources.  She was a stunning older woman of about thirty-five.  At dinner she handed me a leather-bound volume and asked me to select the wine.  Not wanting to appear the fool, and trying to control my geriatric fawning, I pretended to study carefully the wine list.  Not having a clue what wine to choose, I based my selection entirely on the prices.  I had little or no knowledge of the subject; nonetheless, I placed the order with all the cock-sureness of a third-grader reciting the alphabet.

A few moments later Wine-man, dressed in morning attire, returned with a bottle. He angled the bottle towards me while standing as rigid as a concrete lawn statue.  After a few seconds my adult supervisor paused and directed my attention towards Wine-man.  I tried to appear nonplussed—nonplussed is a word that does not get enough play, so I like using it whenever I can.  “You are supposed to tell him that the bottle he is holding is the one you ordered,” the thirty-something instructed me.

“He knows it is the wine I ordered; that is why he brought it.”  I thought they were toying with me and that my sole purpose at dinner was being the straight man.

A few seconds later there was a popping sound, and Wine-man gently placed the disengaged cork on my white linen napkin in a manner similar to how Faberge must have delivered one of his fabled eggs to Tsar Alexander III for his wife Empress Fedorovna.  They were both staring at me; not the Tsar and the Empress—Wine-man and my adult.  “You are supposed to smell the cork,” she prompted.  And so I did.

“Now what?”

“If it smells bad, it means the wine may be bad.”

To which I replied, “This is the Opryland Hotel—have you seen the wine prices?  Opryland doesn’t sell bad wine.”  I began to wonder if I was supposed to be supervising her.  She nudged me with her elbow.  I knew I wasn’t wowing her, and that the chances of me taking the older woman dancing later were diminishing more rapidly than the half-life of a fruit fly.  I smelled the cork.  “It smells like a cork,” I whispered to Wine-man.  He smiled and poured a half inch of wine in my glass.  I thought he was still pulling my lariat.

I looked bemusedly at my mostly empty glass, held it out to him, and asked if I could have more—my sommelier training had made me thirsty.  I would have made a better impression had I been Juggling raw eggs.  Rather than embarrass me further, with a slight nod of her head, my adult instructed the Wine-man that Sommelier 101 was over—I assumed she knew that any further diminution of my nugatory social mores would be of limited marginal value.  I should have ordered beer.  I was good at beer.

For those still reading, if you are wondering if I am actually going to make a point, here it comes.  I think segues are overrated, so don’t blink.

Sometimes, a little guidance is helpful—even if it has to come in the form of being led around like camel with a ring through its nose.

Often, what is important in a leader is having the knowledge and temerity to ask the right question.  In business it is often the case that the number of executives with answers may exceed the number of executives asking questions.  Value is often measured by scarcity.   Good, challenging questions are often in short supply.  So are leaders who do not require adult supervision.

One of my favorite books is “Wild at Heart,” a précises that men—I think it applies to all of us—spend their lives trying to live up to the expectations of their fathers. A subset of its premise is their concern that someone at work will discover that they have spent their careers bluffing about their ability to accomplish what is expected of them.

Is it possible that the difference between aspiring to be excellent—aspiring to be a leader, and being excellent is as simple as leading, as simple as one’s intent?  Not being discovered as a fake?  Does leadership come down to doing what you think is right versus doing what you think others will think as right?

I think many executives have an index card tucked away in the recesses of their minds.  And on that index card are a list of initiatives those executives would undertake if they had their way.  And therein lies the rub.  Some executives choose to manage based on those initiatives—they choose to embrace the implied risk of failing.  Many executives choose to be managed by the risks of those initiatives.

Pretty simple things.  The right things usually are—like knowing what to do with the wine cork.  Even if you can fool all of the people some of the time, sooner or later you will be called upon to choose the wine.  When that moment comes, if the idea of being the person who has to make the choice makes your knees shake, do not compromise. Also, do not pick the rosé.

“If you laugh, you think, and you cry, that’s a heck of a day.” Jimmy Valvano. “If you choose to lead, that is even better.” Paul Roemer

Yesterday morning, five miles into my run, I was feeling pretty good about myself. I had passed seven runners, had a nice comfortable rhythm, no insurmountable aches, and Crosby Stills & Nash banging away through my earbuds. I don’t like being passed—never have. Some people say I’m competitive. They say other things too, but this is a family show.

I’m a mile away from the midpoint of my run when I see a slight blurring movement out of the corner of my left eye. A second later I am passed by a young woman wearing a blue and yellow, midriff-revealing spandex contraption. Her abs are tight enough to bounce a quarter off. She is pushing twins in an ergonomic stroller that looked like it was designed by Sharper Image. I stared at her long enough to notice that not only was she not sweating, she didn’t even appear winded. She returned my glance with a smile that seemed to suggest someone my age should consider doing something less strenuous—like reading. Game, set, match.

Having recovered nicely from yesterday’s ego deflation, today at the gym I decide to work out on a Stairmaster, the one built like a step climber. I place my book on the reading stand, slip on my readers—so much for the Lasik surgery, and start to climb.

Five minutes into my climb, a spandex-clad woman chipper enough to be the Stepford twin of the girl I encountered on my run mounts the adjoining Stairmaster. We exchange pleasantries, she asks what I’m reading, and we return to our respective workouts. The first thing I do is to toss my readers into my running bag. I steal a glance at the settings on her machine and am encouraged that the METS reading on my machine is higher than hers, even though I have no idea whether that is good or bad.

Fifteen minutes, twenty minutes. I am thirsty. Water is dripping off me like I had just showered with one of Kohler’s full body shower fixtures. I want to take a drink and I want to towel off, but I will not be the first to show weakness. Sooner or later she will need a drink. I can hold out, I tell myself. Twenty-five minutes—she breaks. I wait another two minutes before drinking, just to show her I really didn’t need it.
She eyeballs me. Game on. She cranks up her steps per minute to equal mine. Our steps are in synch. I remove my hands from the support bars as a sign that I don’t need the support. Without turning my head, I can see that she’s noticed. She makes a call from her cell to demonstrate that she has the stamina to exercise and talk.

When she hangs up I ask her how long she usually does this machine—we are approaching forty minutes and I am losing feeling in my legs. She casually replies that she does it until she’s tires, indicating she’s got a lot left in her. I tell her I lifted for an hour before I started; she gives me a look to suggest she’s not buying that. I add another ten steps a minute to my pace. She matches me step for step.

Fifty minutes. I’m done toying with her. I tell Spandex I’m not stopping until she does. She simply smiles. Her phone rings and she pauses her machine—be still my heart—and talks for a few minutes. I secretly scale down my pace, placing my towel over the readout hoping she won’t notice. She steps down from the machine. My muscles are screaming for me to quit, but I don’t until I see that she’s left the gym.

Victory at any cost. What’s the point? For what was lost, for what was gained. Men and women. Customers and companies. Patients and health systems. Most will deny they are competing, yet neither will yield. The customer is always right. Turns out it makes a better bumper sticker than it does a business philosophy.

Patients are never right.  They never have the opportunity to be right.  It is difficult to be right when your call is on hold.  It is impossible to be right when you are playing “Where’s Waldo” with a hundred links on the health system’s homepage trying to find a link to schedule an appointment.

The issue I have difficulty wrapping my arms around is why is access as bad as it is?  The solution to improving access is stupefyingly, are-you-smarter-than-fifth-grader simple.

Tomorrow is national “Fix Patient Access Day.”

You have no incentive to fix something that you don’t know is broken.  So here is my patient access twelve-step program.  “Hi, my name is (state your name), and I have an access problem.

Close your office door. Sit at your desk.  Now pretend you are a person trying to buy healthcare, or that you are a patient trying to access your provider.

Navigate to your health system’s homepage and take it for a test drive.  Your experience should be a little like what Alice encountered when she was looking for the rabbit hole.  Hidden among the hundreds of website links and the dozens of phone numbers may be a link that allows you to do something other than post photos of your new baby.  After a few hours of browsing and not finding an actual way to access the health system, it is best to give up.

The next exercise in futility is to try to access your health system by calling one of the numbers posted on the website. Nota bene—if you call at a time other than 8 A.M. to 6 P.M. Monday through Friday, you have to go back to Step 1.

You will encounter one of the following; a recorded message telling you how important your call is and that it may be recorded for quality purposes—a note of warning to members of the C-suite.  Your inclination will be to throw the phone against the wall and go directly to the executive dining room.  You are placed in the waiting queue.  Celine Dion’s music is piped through the phone.  You are midway through the second CD of her greatest hits—assuming she had a greatest hit—when a voice asks how you can be helped.

Nota bene²—I had to Google to learn how to do the superscript.  Unless you are going to ask to schedule an appointment, a request with about a 60:40 chance of being successful, your call is about to be transferred because schedulers are only able to schedule calls—they cannot help you with other questions.  Your call is transferred.  You are placed on hold again.  Celine is still singing her heart out.

I know how cynical this all sounds.  It would be funny if there wasn’t a lot of truth in it.

Good access is so simple it is silly.  People, patient people and prospective patient people need to communicate with your health system.  They do not want to call it, but given that they cannot accomplish anything online, calling is their only choice.

Step Two of the Access Twelve-Step program is acknowledging that access is broken; badly broken.  Steps Three through Twelve are up to you.  You either take the steps to fix it or you don’t.

In the 16th century Giordano Bruno, a cosmologist, published a theory that the universe was infinite, and that there was no celestial body at its center.  His theory contradicted the teachings of the Catholic church. He was tried for heresy and burned at the stake.

To those who think my published theories that patients are the center of healthcare are heretical, I have hidden all your matches.

Seventy-six percent of health systems in the U.S. spend $100,000 or less annually to improve patient experience (PX).  To put that in terms understood by the readers of People Magazine, the expenditure is less than 1% of what Kim Kardashian spent on her wedding.  It also means that whoever is leading the PX effort at those systems would earn more if their most repeated phrase was, “Do you want fries with your order?”

Nine of every ten healthcare executives say that improving PX is one of their top five priorities.  Is it fair then to ask if their other four top priorities at three out of every four health systems are also funded at less than $100,000?

Forty-five percent of health system executives say they would rate their systems’ efforts to improve PX as fair or poor.

So what do we know if the statistics are to be believed?  One of every two healthcare executives rate their PX low.  Nine of ten say it is a priority.  Three of four spent less on improving it than they spent on the car they drive to work every day.  If we drew this as a Venn diagram none of the circles would intersect.

The good news is that the 45% figure of those who rate their systems’ PX as low is twice as high as the number of Americans who believe the earth is flat—so, that is something on which we can hang our hats.  Forty-five percent is also roughly equal to the number of Americans who believe that the government is covering up the fact that cell phones cause cancer, and who believe extraterrestrials exist.

“Survey says…”

The numbers make no sense; especially when you consider that the average lifetime value of a single patient is around $200,000—unless the lifetime value is zero because the patient’s experience was so bad the patient went somewhere else.