I was awoken by a strobe of orange light flashing through the bedroom windows.  I looked out and saw a human caravan making their way to my backyard.  By the time I had dressed and made my way out the deck door, I saw two men hammering wood stakes into the wet ground, and a woman stringing what looked like crime-scene tape around the stakes.  Another half-dozen people were talking on phones and writing on clipboards while a lone woman was collecting water in test tubes.

The grass was sodden from the recent rains. As I approached the group a guy built like a linebacker approached me and asked, “Where do you think you are going Skippy?”

“Why is everyone in my backyard and standing around my puddle?” I asked.

“It was your puddle, now it’s a wetland.  Go back inside voluntarily,” he said as he reached for what looked like a Taser.

To my left was another puddle, one they had yet to rope-off.  I flopped into it on my back and started moving my arms and legs.  The Taser was now pointed at my head.  “What are you doing? He screamed.

“Making wetland angels,” I replied.  “I think I may have just been bitten by a rare, yellow-bellied newt.”

The world is changing faster than I can yell tree-sloth, and I didn’t even get the email.

Several of you wrote asking me to give an example of the differences between a well-functioning call center and the scheduling centers found in most health systems.  This may help.

I pulled together a meeting with James and Betty.  James works for your scheduling center; you probably seen him in the cafeteria—tall, lanky…parts his hair on the left.  Betty works for Nordstrom.  I asked them to tell us what their job is like and what they do during their shift.

James began. “My job reminds me of one of those people I’ve seen at a driving range,” he said.  “If you’ve ever hit balls at a driving range, you may have seen a person driving around on the range in what looks like a metal birdcage.  It looks like a wheeled metal box wrapped in wire, and it is pulling a long, rubber, grooved cylinder.  The grooves pick up the driving range balls, and they are dropped into a collection basket.”

“I’ve seen those when I golf,” I said.  “Everyone tries to hit the cart with their shots.”

“Exactly.  That is what it feels like answering calls at the scheduling center.  Everyone is shooting at me and I just have to sit there and take it.  I bet you didn’t know that only about twenty percent of the calls I answer are from someone trying to schedule an appointment.”

“What do you do with the rest of the calls?”

“Sometimes I try to answer them, but I don’t have any of the tools or information I need.  So, I either tell them to call another number—that may or may not be the right number—or I transfer the caller to someone who may or may not be able to answer their call correctly.  Sometimes I find myself giving basic medical advice.”

“Don’t you have a nurse that can do that?”

“You’re kidding, right?  Heck, we don’t even have a decent scheduling system to be able to enable me to do my job.  I bet I am only able to schedule sixty percent of the people who need an appointment.”

That was James. Betty’s response was just as interesting.

“Have you ever been to a big city park where they have dozens of chessboards set up?” I nodded affirmatively.  “Well sometimes a master chess player will play dozens of games simultaneously, the master against all of the others.  That is what my job at Nordstrom’s call center feels like.  No two questions are the same, and I am expected to give the right answer to every caller the first time, every time.  But I have a CRM systems that lets me know the answers to every question.”

“So, let’s say I call you about a problem I had with a suit I purchased and had tailored at one of your Seattle stores.  Could you help me with that even though I bought it in Philly?”  I heard her enter my phone number into her system.

“The one you bought June 3^rd, the Ted Baker pinstriped?  I see you called once before.  It looks like the alterations to the pants were incorrect, and they applied a credit to your account.  You shipped it back to be re-altered on the 11^th.  The alterations were finished on the 23^rd.”

“I still have not received it.”  More keyboard clicks.  It shipped yesterday, overnight, along with a tie picked out by your personal shopper; no charge for the tie.  May I help you with anything else?”

There is a world of difference between what a health system’s scheduling center can do and what a real call center can do.

I just realized that I was supposed to have scheduled my MRI yesterday.

What should I do?  What would you do?  I dialed the phone.  “Betty, there is one more thing you can help me with…”

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.

The Animal Planet channel is advertising a show, Treetop Cat Rescue about rescuing cats that climbed a tree. The premise of the show must be that cats only know one way to climb; up. I have never seen a cat skeleton in a tree or on a roof.  That got me thinking; either there are a lot of cat rescuers who are very good at what they do, or the cats do not need rescuing and they are able to find their own way down.

Keeping with the cat theme.  While I was on vacation my mother and brother were taking turns checking on my house and bringing up the mail.  My brother called three days into my trip, and told me that cat died.  I said, “You can’t just drop that kind of news on someone.  You have to work up to it gradually.”

“And how do you propose I should have done that?” He asked.

I said, “You start off slowly, maybe saying something like the cat got out and it climbed up the side of the house, and now the cat’s on to the roof, and it won’t come down.  And you tried to get it down using a ladder, but the ladder was not long enough.  Then you say you called animal rescue, and a guy got hold of the cat, but the cat jumped out of his arms and died.

Two days later I called him again.  “How is everything going?”  I asked.

He was quiet for a few seconds, and said, “Mom’s on the roof, and she won’t come down.”

Sometimes it is about the words we use.  Sometimes it is about how we use the words.  Occasionally it has to do with the meanings others take away when they hear the words.  And that mnemonic certainly plays itself out in healthcare.

The words; access, engagement, experience.

Let’s try to level-set this for a moment.  What are they in your organization; nouns, verbs?  I think they are business processes, but for them to be processes they would have to exist, they would have to have a beginning and an end.

I got a call last week from an executive of a very large health system.  She said, “All three of these processes are on the roof and they won’t come down”.  (Try herding cats.)

One characteristic of a process is that you can watch it; you can watch it from start to finish.  And you can map it, assess it, and move the bits and pieces around to optimize it.

Can anyone at your health system map any of those three processes from start to finish?  Highly unlikely.  And it is unlikely because if they could, they would, and then they would find out that they probably missed ninety percent of the process.

There is a very good health system in Washington—not the state—with the letters GEORGE in its name.  Its entire, enterprise-wide access department is four women in a closet-sized office who provide registration services for patients the day before surgery. If I had blinked I would have missed it.  Goodness knows all of that health system’s other stakeholders have been missing it for years.

One can deduce that if a health system has taken the trouble to define what access is, by default it has also defined what access isn’t.  The good news in the case of this health system is that the people in its transformation and innovation department can map out their entire access process during lunch on the back of a cocktail napkin.

Most health systems believe access, engagement, and experience are important.  Important enough to warrant assigning three separate teams of people to deal with them.  Three separate teams dealing with three separate, different problems—perhaps as different as oncology, cardiology, and epidemiology.  It is difficult to find fault with that approach unless access, engagement, and experience are not like oncology, cardiology, and epidemiology; unless of course access, engagement, and experience are one in the same.

By the time in the process health systems concern themselves with what is happening regarding the access, engagement and experience of consumers (people deciding where they will buy healthcare) those are no longer issues for many of its consumers.  Those consumers are gone.  Gone because of very poor access and zero engagement.  And those are two of the three components of experience.

To understand someone’s experience you do not have to measure it, analyze it, or survey it.  Those tools are only needed by health systems who have already lost the patient experience battle.  By the time they think they need to get their tools out, the experiences of many people have already been cast.  The only output of value from those tools is to tell the system by how much it has lost the battle.  Just because your system may have a good HCAHPS score does not invalidate it having lost the access/engagement battle.  My rule of thumb is that the more fervent a system’s focus is on HCAHPS the less it knows about wat is occurring outside of HCAHPS.

The third component of everyone’s experience, the component sitting alone in the waiting room, or waiting on hold on the phone, is expectations.  And nobody can tell you anyone’s expectations for one simple reason—nobody every bothered to ask.

Until people in your health system believe it is important to ask patients and consumers what they expect when they interact with it, until they develop a plan to meet those expectations, there is no reason for anyone to believe any of the rhetoric about how important your experience is.

Remember however, “Your call may be recorded for quality purposes.” Or maybe not.

“The time has come,” the Walrus said,
“To talk of many things:
Of shoes–and ships–and sealing-wax–
Of cabbages–and kings–
And why the sea is boiling hot–
And whether pigs have wings.”

Gibberish (I thought Jibberish was spelled with a J) is good, and often insightful.

Sometimes I have to rack my brain to decide what to write; other times it is handed to me, just begging for a response.  This is one of the “other” times.

In the fable of “Chicken Little” the chicken believes the sky is falling because an acorn fell on its head—the chicken was wrong.  In the fable “The boy who cried wolf” the people in the village are fooled into believing a wolf is attacking their village.  The people are wrong.

In the CMS fable “Everything a hospital ever needed to concern itself with regarding patient experience,” CMS is wrong.  And to make matters worse, CMS has all of the providers focusing all of their efforts on catching the wolf.  What many do not recognize is that providers would have been doing these things with or without the hard hand of CMS.

It is much more difficult to find the needle in the haystack when you are not on the same road as the haystack.  Hospitals have already found many of the needles.  Their problem is that the remaining needles are smaller and smaller, and more difficult to find.  Thus, finding each subsequent needle costs more.  Hospitals have also missed the fact that right next to the CMS haystack are other haystacks with needles the size of javelins waiting to be found.

What if two customer experience surveys were compared side-by-side.  One for hospitals and one for hotels.  Might they look like this?

No one is arguing that for hospitals to be successful at patient experience that they need to think of themselves as hotels.  No one is arguing that hospitals should stop trying to manage pain or to reduce noise.  The argument is that there are plenty of other things hospitals could be doing to complement their current initiatives, things which would have a much greater impact on improving experience.

What is the business problem hospitals are trying to solve as they wrestle with what to do about patient experience?  Are hospitals trying to create a remarkable experience for every person every time?  If they were their approach would be entirely different.  Are they trying to retain patients, to earn referrals, to capture a higher percentage of their receivables?  If they were their approach would be entirely different.

The problem hospitals are trying to solve is to avoid the CMS penalty.  Hospitals’ expenditures of people and capital are not targeted to solve an actual business problem; the expenditures are to avoid a problem created for them.

A recent trade journal survey asked, and the article reported answers to the following questions:

• What is the number one goal of your patient experience efforts?
• In which of the following patient-related areas do you expect your organization to focus over the next three years for patient experience improvements?
• Please rank your motivations for investing time or resources to improve patient experience scores
• Who has the primary responsibility for patient experience in your organization?

The number one goal reported by hospital executives was ‘improved’ HCAHP scores. So, let us assume the hospital achieved its goal and rocketed to the first quartile, thus removing itself from CMS’ penalty.  What do they get from that achievement? Retention, referrals? Nope.

Is this goal an example of keeping ones focus on the hole versus the doughnut?  None of the responses listed any mention of the word ‘patient.’ Less than one in ten respondents addressed improving market share, not that the planned efforts will do much to improve share. And, none of the responses mentioned making any effort to retain patients or to attract prospective patients.

According to the survey results, hospitals’ primary focus are on trying to meet an artificial benchmark created by CMS without knowing whether achieving this benchmark is the best thing they could be doing to create a remarkable experience for every person every time.

Improving patient experience is an issue that has the attention of most hospitals.  Yet the solutions being proposed seem to be sorely lacking the following initiatives:

1. Innovation
2. Transformation
3. User Experience
4. Disruption

Who is responsible for the experiences of the prospective patients? Apparently nobody.  Who is responsible for the experiences of people before they come to the hospital, after they are discharged, and of those wondering if they should seek a second opinion from another hospital?  If hospitals cannot agree as to who is responsible for their current assets (patients), then we can be certain that nobody is responsible for the experience or satisfaction of prospective patients (their future assets) or for those patients seeking a second opinion.

The tallied survey responses seem to be all about raising HCAHP scores and avoiding penalties; not about improving the experience or patients and prospective patients.  Does that seem to be the case in your organization?

I estimate that the lifetime value of a patient is somewhere between $180,000-$250,000.  That means that a retained patient and a prospective patient are also worth that amount.  Add to that the revenues of a patient’s family and friends and all of a sudden we are looking at numbers that demand innovation and transformation around patient experience.

Patient Equity Management. Family Equity Management.

A remarkable experience for every person every time on any device.  If this is your goal, the value of having your primary focus be on reducing noise, way finding and better housekeeping, needs to be rethunk.

I may be wrong, but I doubt it.

If your 2018 business strategy does not account for providing healthcare like this you have already lost.

I moved to town last night. I am staying in a hotel while I look for a place to live, and this morning I am in my car driving to my new office for the first time.  I am not feeling well; far from it.  I tell the Bluetooth device in my rental car to connect me to VideoDoc-Roemer.com.  Using the car’s GPS the service connects me to a doctor in my area.

A face pops up on the car’s dashboard touchscreen and a voice comes through the cars speakers, “This is doctor Velasquez. Am I speaking with Paul Roemer?”

“You are, thank you for taking my call.”

“How may I help you?”

“I just relocated and I have not had time to find a local doctor or to get my medical records sent here.  I have heart disease, and with everything I had to do, I forgot to pack my nitroglycerine.  I am feeling a stressed, I am breaking out in a cold sweat, and I am feeling a little dizzy.  It’s probably nothing, but is there any way you could write me a script for the nitro?”  We talked for a few minutes.

“Where should I send the script? The Doctor asked.

“I can’t even remember the address of my hotel,” I told her. “But Amazon has the address of my new office.  Can you work with that?  I should add that my left shoulder is feeling a little tight.”

“You bet. I can have Amazon’s RxRobot deliver it to your office today.”

…

“Mr. Roemer?  Can you still hear me?”…A minute passes.

“Mr. Roemer, I have your GPS location, and I dispatched an ambulance to your location. If you can, please pull over.”

That is tomorrow’s scenario, and it pretty much exists today; unless of course the patient is dealing with a health system.  Plus or minus a Bluetooth solution with an in-car video screen, some of the options available to every prospective patient are Walgreens, the Minute Clinic, Doctors on Demand, and urgent care.

Today’s scenario, if played out with a health system, would likely involve having to call a hospital to schedule an appointment with a cardiologist. It may require a wait of several months to be seen.

Everything described above, minus the robot delivery of medication, exists today.  To those who want to argue that a robot cannot deliver medications by robot because it would violate CMS’s HICCUP (sic) requirements, that is not my point. The point is that healthcare has changed except for those institutions which believe that they are healthcare.  They may have been healthcare, and they may still be healthcare, but unless they vigorously change how they deliver and market their services, they will not be healthcare.

Healthcare has already changed.  The only group that did not get the email are America’s healthcare providers.  Offering free Wi-Fi in your waiting rooms does not qualify as an ante at the innovation conference.  Walgreens’ telemedicine services are available in twenty-five states. Minute Clinic. Doctors on Demand.  Versus your health system where your patient is making their third call to schedule an appointment, an appointment where the next available opening is three months from now.  By the time your health system is ready to see the patient for an initial appointment, the patient with the heart disease is twelve weeks removed from having received their stent.

So this morning I met with the COO of a large health system. I had sent him a brief PowerPoint deck outlining what I thought he needed to do to prepare his health system for what was happening. He told me he had already prepared for the change.

“We know the delivery of healthcare has changed from the being fixated on the delivery of acute care to being able to respond in real time to delivering ambulatory services.  To adapt to that change, we made some changes.”

He pointed to what used to be their grand lobby. “Instead of wasting this space, we turned it into an indoor volleyball court.  You’ll have to excuse the sand, but we have tournaments going every night of the week.  And if someone gets hurt, we can treat them right away. We turned the entire basement cafeteria into a global food court.  Our patients, staff, and visitors use the GrubHub app to have the meal of their choice delivered—I really like the Thai deli.  We turned each of our twenty-seven waiting areas into spas, twelve of which have hot tubs.  And we got the use of the spas preapproved by the payers.  So we are very well positioned to combat how healthcare is changing.”

So let’s make this personal.  Let’s take the discussion to the board room of your health system.  How prepared is it to compete?  It is no longer sufficient to simply offer care, no longer sufficient to even offer the best care.  Your customers—you can substitute the word patient if it makes you feel more comfortable want healthcare services now, and they are prepared to try new ways to obtain those services.  And guess what?  If patients find that having real time access to those services works, they will not walk back the cat and revert to the old way of accessing care.

Let’s be honest, the innovation train has left the station.  If your health system was prepared, if your health system is prepared, it would not be questioning whether it should be amending its 2018 business strategy, it would already be hard at work figuring out how to offer these services.

Instead of trying to ameliorate patients by trying to find alternatives to scheduling appointments 90 days out, your health system would be connecting people to appointments on the phone and people on the website by offering real-time appointments. “Would you like a video appointment with a board certified cardiologist this afternoon at 2?  We can send you the link to the software you need, and an easy video that shows you how to login and how to test the microphone and the camera.  This service costs twenty percent less than an office appointment and the entire cost is covered by your insurance.”

An easy button.  Your health system can be the ostrich with its head in the sand and continue to ignore this, or it can announce the formation of an innovation group tomorrow.  Healthcare innovation is not tied to purchasing another MRI device, and it is not tied to a new way to treating an obscure illness.

People, your patients, have redefined what having access to healthcare means to them.  Access to healthcare from their perspective means access today, access now, access when and where they want it.  If your health system does not offer what they want, they will find what they require on their own.

The temperature was in the mid-nineties and the humidity was not far behind.  Nine miles into my run I was approaching the crest of the bridge crossing the bay, and I was leaning over the guardrail to catch my breath. I was dog-tired, dehydrated, and my feet felt like they had swollen to twice their normal size.

To my surprise, a state policeman, kitted out smartly in his pressed uniform, pulled alongside of me. “What are you doing on my bridge?”  He asked from the cool confinement of his air-conditioned patrol car, an undisguised tone of concern in his voice. To hear him I removed one of my earbuds; I had been listening to the local sports-talk radio station.

I saw my face reflected in his Ray Ban Aviator sunglasses.  Since I was trying to cross the bridge, I thought about asking him if his question was like why did the chicken cross the road, but he did not look like a chicken crossing the road kind of guy.

“Are you okay? You don’t look okay.”

“I’m fine. Why did you pull me over?” I asked. “I just heard on the radio a report saying there is a guy who looks like he may be ready to jump off a bridge.”

“I got several calls about a guy on the bridge who looked depressed. Are you thinking of jumping?”

“Am I thinking of jumping what?”

“Jumping off the bridge. Are you sure you are okay? You look depressed.”

“I think I look like I just ran nine miles.” I placed my right leg on the top guardrail to stretch my hamstring.  Below me a small armada of boats had dropped anchor and the passengers appeared to be having impromptu tail-gate parties in the middle of the bay.  Everyone was looking up at me, and some appeared to be filming, so I waved. A few of the people were yelling for me to jump.

I could hear the thwump-thwump of a television news helicopter as is hovered overhead, a parabolic microphone pointed in my direction. (I embellished a little to make for a better story, but it’s my blog.)

“Take your leg off the bridge, and back up slowly” the officer commanded as he moved slowly closer to me. “I was about to call for a police helicopter. Are you sure you are okay?”

To me the entire dialog was starting to sound like a bad Leonard Cohen verse. I was going to ask him if the helicopter would give me a ride back to our house in Ocean City, but he didn’t look like a give me a ride back kind of guy. If I continued across the bridge, home was only two miles away.  If he did not let me cross I had to double-back those same nine miles. “May I continue across?”

“No, you can’t do that from here.”

An interesting statement, You can’t do that from here.

I was analyzing a hospital’s website. There was a link on the homepage stating that if I clicked it I would be able to schedule an appointment.  It was right next to the link telling me that if I clicked it three times I could continue across the bridge and go home.

I clicked the scheduling link. The next webpage told me how much they wanted to help me schedule an appointment and how important my health was to them. The following webpage told me about all of the services I could schedule. The final webpage told me that if I wanted to schedule an appointment that I should call the hospital Monday through Friday between eight A.M. and five P.M.

The website’s scheduling webpage should have included 24-point bold disclaimer stating, You can’t do that from here.

Like trying to cross the bridge.

Understanding people can be like trying to understand a Picasso painting.  Half the country believes gun control means using both hands.  Ninety percent of the country believes in ghosts. A fair share believe in Sasquatch and an equal number believe the moon landing never happened.  Thirty-five percent can correctly identify Homer Simpson’s fictional home town, yet less than one percent knows the name Thurgood Marshall.

All of these same people belong to one of two groups.  They are either patients or prospective patients of your health system.

I had been invited to peek behind the green curtain and was off to meet the wizard. The health system’s marketing strategic planning meeting was already underway when I was ushered in. In the room were the Chief Marketing Officer, the system’s head of business development, someone from IT—because every meeting always has someone from IT in attendance, and a handful of analysts.  The young fellow responsible for the system’s Facebook page and Twitter account was also present.  Along the far wall, seated next to the nearly empty tray of bagels was a somber-looking retired gentleman—more on him later.

Taped along the walls were large sheets of paper displaying the results of their brain-storming session. Each sheet listed initiatives around a specific marketing tactic to be deployed over the next twelve months.  There was a sheet extolling the benefits of advertising on NPR. Right next to it was a sheet discussing a billboard marketing initiative.  Apparently, still to be decided was whether a group photo of the urologists would generate more new patients than a group photo of the podiatrists.

The IT gal had her own sheet.  She would be responsible for the dialing for dollars campaign—telemarketing calls.  A fourth sheet focused entirely on the elevator campaign.  I deduced that the elevator campaign dealt exclusively with taping a sheet of paper to the back wall of every elevator describing whichever initiative was being marketed each month.  June is stop-smoking month, July is stop-drinking month, and August is stop-eating month. I thought about mentioning that nobody would read what is on the piece of paper because people in elevators tend to face forward, but I did not want to be tossed out of the meeting until I saw what they were serving for lunch.

Probably because she sensed I was getting antsy, the Chief Marketing Officer asked me if I had any questions, or whether I cared to make a contribution.  I shifted around on my chair and I tried to look like I was being reflective.  Rising slowly, I moved from page to page, my hands clasped behind me.

“What does it cost to acquire a new patient?” I asked. “And do you think your department covers its own costs?”

The person seated next to the Chief Marketing Officer leaned over to her and whispered, “You said there wasn’t going to be a test.”

“Nobody knows,” she replied. She gave similar answers to questions like; “How many new patients did marketing acquire last year?” “Which campaigns worked the best?” “How many people who try to sign up for a program are never heard from again?”

Then I asked if they could point to anyone who had ever become their patient as a direct result of a marketing initiative.

“That is why Walter is here,” she said as she pointed to the retired gentleman.  “He saw one of our billboards twenty years ago, parked his car, and became a patient. We bring him to every one of our meetings to give us inspiration.”

“If you had to state the goal of the marketing department in one phrase what would you say?”  The guy who asked about there being a test was starting to look very dismayed.

“The goal is to get someone interested enough in our hospital to call us.”

A few more questions uncovered that prospective patients—consumers—call the scheduling center (It’s like a call center, only much less functional).  Sometimes the schedulers receive a flier describing the campaign, and they tape the flier to their cubicle. Other times, they have no idea what the caller is asking about, nor are they able to help the caller.

Health systems spend a lot of money trying to acquire patients.  In reality, I think they spend a lot of money trying to generate enough interest to get someone to call. I think they spend almost no money trying to acquire or capture the interested person.  It’s like spending a lot of money on a hand-made graphite fly-rod and a pair of neoprene waders and giving the gear to someone else who you hope knows how to set the hook in the mouth of a fish.

The acquisition part of marketing is the part where the person interested in one of your system’s services commits to buying the service. The only place acquisition can happen is during the access process, by phone, and that process is broken.

Marketing works hard to attract new patients, yet nobody is working hard to capture them, to set the hook. The prospective patients disappear.  I guess that is a little like what happens with patient leakage.  But nobody is working hard to capture them either.

People are disappearing left and right.  People who are worth around two hundred thousand dollars to a health system. I may have spotted one of the disappeared in the hallway, but it could have been Sasquatch. I believe improving access could cut the number of disappeared significantly.  But I also believe we landed on the moon so I could be wrong.

My wife and I were up at four AM, and reached the hospital on the outskirts of Philadelphia at six.  The very first sign we saw was this announcement, “Valet Parking for Handicapped Patients is $2 off.” Has I been handicapped and arriving for surgery without having had my coffee, the two dollar discount would have me waiting with baited breath for the opportunity to complete my customer satisfaction survey.

I had a few hours until my wife would be discharged, and I turned to the hospital’s web site to see if it provided an experience any more remarkable than the parking.  At first blush it looked like there were links to everything.  Many of the links led to black holes; you followed a succession of webpages until you hit a dead end.  You were unable to accomplish whatever it was you set out to do, but there was enough stuff to click on to make it feel like there must be a pony hidden somewhere amongst the detritus.

There was a link if to donate, one for doctors, one for nurses, one for members of the board, more than two-dozen phone numbers, some videos, how to follow them on social media—displayed in two different places, links to teach you how to ‘eat on the go’ and how to know if you are pregnant—go to CVS, a place to view all of their awards, health information, directions, contact information, and even one for patient and visitor information.

Your health system’s website should not be a catchall for everything someone in IT can dream up. I would estimate that more than ninety-five percent of visitors to your website are either patients or potential patients. Yet, the link for patients is no more prominent than the link for posting baby photos.

Many health system home pages have the look and feel of the Craigslist website, but without the functionality.

Fifty percent of patients go to a hospital’s website to determine if they will get a second opinion.  Eighty percent will visit it to determine if they will become your patient.  Behind which of those links is the information that will help them make their decision?  Which bit of information will cause them to stick with your hospital?

Some people are all set to buy healthcare from another hospital, yet they are at your web site to see if maybe they should go with you.  Some people are all set to buy healthcare from your hospital, yet they are at your website to see if maybe they should go somewhere else.

Has anyone in your health system ever asked either group of people what they need to find on your website to get them to select your organization and then designed a website to accomplish that?

According to Nielsen, users will stay on a web page for 10-20 seconds.  First time visitors spend less than that. If they do not find a value proposition, something to compel them to stay they leave.  The average visitor only reads twenty percent of what is on the page.  Look at your hospital’s homepage.  Think about how much you can accomplish in ten seconds.  If you were thinking of seeking a second opinion, could you even find what you were looking for?  On average, 70% of people leave the site, and hence purchase healthcare somewhere else because they could not find what they needed.

They were dissatisfied.

They had a bad experience.

Patient experience occurs before someone gets to the hospital, and it occurs outside of the physical building.  But they will never get to the building if their online experience and their phone experience compels them to look elsewhere.

The woman in front of me at the checkout line in the grocery store had two shopping carts piled to the rim with food.  She began placing her items on the belt, one item at a time, sorting them into neat categories; perishables, organic, canned goods.  I tried using ventriloquism, repeating the phrase “get out of the line…get out of the line.”  I could see her looking around trying to place the voice, but she remained fixated on her sorting…place the frozen Salisbury steak next to the TV dinners.

I felt a bead of cold sweat trickle down between my shoulder blades, and a slight shiver overtook me. I started picturing the woman in front of me at a salad bar, inspecting individual chickpeas prior to placing them on her plate.  The only other thing that could have made my morning more untenable is if the grocer decided to play a Celine Dion CD over the loud speakers.

After about twenty minutes the last of her items had been scanned, and the clerk announced the amount. The woman fumbled about in her purse, pulled out a large white envelope, and from it she withdrew a fistful of coupons.  The voice in my head whispered to me “I thought we agreed there would be no killing this time.”  Ten more long minutes passed; my grapes were turning into raisins.

The store manager and I simultaneously saw her reach back into her purse.  Even before we saw it, we both knew she was reaching for her checkbook.  The manager knew he only had a couple of seconds to try to stop the bedlam that was about to explode.  He vaulted the service counter, pushed aside the boy bagging the groceries and flung me to the floor.  A Good Samaritan in the next aisle straddled my legs while the manager hooked me up to an IV of Benadryl, and shielded my view from the woman.

That was my day.

If experience teaches us anything it teaches that if we represented the people who think they understand business strategy and planning on a Venn diagram, and also represented the people who actually understand business strategy and planning on the same diagram, the number of those who actually understand it would be like comparing the circumference of the donut to the circumference of the donut hole.

About one hospital in seven has a defined customer/patient experience strategy, and of those that do almost all of those strategies focus exclusively on what occurs within the hospital, and almost all of them rely exclusively on improving HCAHP scores.

That said, we can make a few observations about why it is difficult for any hospital to make any significant improvements regarding patient experience:

• 85% of hospitals do not have a system-wide experience strategy even though ninety percent of hospital executives rank improving patient experience as their first or second priority over the next three to five years.
• Of the fifteen percent with a strategy the vast majority of those strategies are constrained by what occurs to the patient in the hospital.
• Most hospitals do not measure the experiences or levels of satisfaction of their outpatients, former patients, or family members.
• It is possible that no hospitals measure the experiences or levels of satisfaction of prospective patients.

Should providers be improving HCAHP scores or improving patient experience? While it may seem like splitting hairs, the two efforts are not the same. You can improve the scores without improving the experience, but you cannot improve the experience without having it raise the scores.

What is the health system’s definition of improvement?  Where is the plan?  For most health systems the goal is to raise their score. Move the number from A to B. But then what? Where is the strategy? What is the retention goal?  The referral goal?

Not a single patient or consumer in the country can tell you the HCAHPS score of their health system. I bet none of Press Ganey’s employees can tell you the score of their provider.  HCAHPS are so material that they have become immaterial.  They are immaterial because nobody ever asked a patient what experiences are material to them.

And what is the pink unicorn in the patient experience waiting room, what is the question nobody is asking? It is this—why are providers trying to improve their scores? Managing HCAHPS is an aversion strategy mandated by the finance department.  It is similar to meeting Meaningful Use; maximize the EHR rebate and avoid the penalty. Other than not being penalized, how does the provider benefit from having a higher score?

Alternatively, how would a provider benefit by actually improving patient experience? Actually improving patient experience, patient access and patient engagement results in:

• Higher patient retention
• Higher patient referrals
• Improved revenue cycle
• Lower customer service costs
• Reduced admissions and readmissions

Now that seems to be a strategy that I were I the CEO or CFO or COO or CNO I could get my arms around.

Playing a trivia game as an ice-breaker at a networking event, the question was, “A five-letter word for a reptile.”

The woman next to me shouted out, “Spider!” (For those of you who may not be herpetologists and who did not win the Scripps Spelling Bee, spider has six letters and spiders are not reptiles.)  Hence my angst.

Foolishly I hoped the woman wasn’t actually replying to the question, but was responding to the fact that perhaps a Brazilian Wandering Spider—the deadliest spider on the planet—had just entered her alimentary canal.

As it turned out, there was no spider in her ear, and there was not much between her ears. My IQ dropped several notches. I decided that I had broken enough ice for one day.

I looked at my wife.  She told me she had to call Dallas.

“All of it?” I asked. She rolled her eyes at me. I am a stickler for syntax, for terminology. I think when we use words we should, at a minimum, know the meaning of the words we use.

Anyway, let’s look at what healthcare can learn from the airline industry for a second. Whose experiences does the airline industry care about?  Only one group of passengers seem to matter.  This group boards first.  They are sipping mimosas while the rest of the cattle are herded to the rear of the plane.  They have their own rest room. And when they are hungry someone places a linen table cloth on their tray table, and they are given baby salt-and-pepper shakers with which they can season their filets.  The rest of us, those whose experiences do not matter, are trying to figure out how to allocate the contents of a bag of peanuts across four time zones.

The airline does not care about the experiences of the other ninety percent of the passengers on the plane.  And here’s the kicker. They do not care about the experiences of anyone before they get on the plane, and they do not care about the experiences of anyone after they leave the plane.

Let us take a minute to define who and what we are talking about when we use the word patient. A health system needs patients who are committed to their system—the chicken is involved with breakfast, the pig is committed.

I posit that from the patient’s perspective the word patient has a much broader definition than the way most health systems define it. Health systems, for the most part, define patient as someone undergoing a billable event. Someone producing revenue in real-time.

I believe there are five types of patients, patient personas.  Each persona has a specific question they are trying to answer when they try to access a health system:

• Consumers: Will I buy healthcare from this institution
• Outpatients: Will I but more healthcare from this institution?
• Inpatients: Committed, at least for the moment to the institution. Will I buy healthcare again from this institution?
• Discharged patients: Will I buy healthcare again from this institution?
• Former patients: Will I buy healthcare again from this institution?

The best way to get a patient committed to an institution is to know a patient’s expectations, and to meet or exceed those expectations by delivering a great experience.  And whose experiences does the health system know? Just those of the inpatient.  And which of those experiences do they know? Only the ones experienced in the hospital?

And why is that important?  Because a lot of experiences happen before the person is admitted and after they are discharged.

Health systems only measure and address the experiences of inpatients in the hospital—like only caring about the experiences of the first class passengers during the flight.

If the personas of a person’s patient life-cycle can be traced from consumer, to outpatient, to inpatient, to discharged patient to former patient, the hospital knows almost nothing about those experiences.  It’s not like those experiences are unknowable.  Health systems made a deliberate choice not to care about those experiences.

Yesterday, the COO of a health system asked me if I had any interest in interviewing for the position of Chief Patient Experience Officer.  I asked her if her health system had any interest in addressing any of the experiences other than those measured by HCAHPS.  She said she didn’t, and I said I didn’t.  Maybe nothing will change until CMS decides to penalize a health system for requiring three phone calls to schedule an appointment.

I would write more but I have a flight to catch. I wish I could remember where I left that bag of peanuts.