Step 1: Find A Big Empty Room
Step 2: Buy a bunch of phones
Step 3: Fill the big room with the phones and people
Step 4: Check the DONE box
There are better ways to approach creating a call center. Ways that involve figuring out what business problems you are trying to solve. Otherwise, your call center will be nothing more than a big room with a lot of phones in it.
I was sitting alone in my client’s office, observing some of the bric-a-brac she had collected during her career. On one wall was a photograph of her and a former president. The credenza above her desk contained white binders of what appeared to be various user manuals, each one filed chronologically from left to right. One binder was labeled, The Purpose Of A Call Center—The Big Room With All The Phones In It. To the right of it was one labeled, What To Do In The Event Of A Soviet Attack.
The photograph made me wonder how many people had their picture taken with a U.S. president. Let’s say the president takes one hundred pictures a day. That amounts to around a hundred and fifty thousand photographs during a four-year term.
And here is what I think is noteworthy about having your picture taken with the president. I am willing to bet that ninety-nine percent of the people who have their picture taken with the president display that picture prominently in their home or office. They do so because they want to remember the experience, and because they want others to know of their experience.
Having your picture taken with the president is a big deal. You remember everything about that experience; the date, what you were wearing, even what you ate for breakfast that day.
Now for the irony. If you were to visit the Oval Office, or the president’s living quarters on the second floor of the White House, you would learn that he does not have the photo of the two of you displayed in a prominent position. In fact, he does not have it displayed anywhere. Nor does he have any of the other one hundred and fifty thousand photos on display. Pressed, he will not remember the date he was photographed with you, what he was wearing, or what he ate for breakfast that day. He would not even remember you if he sat next to you on the plane.
Here is the distinction. He is the only president you met, so it is easy for you to remember the experience. You however are merely one of a hundred and fifty thousand people he met, and chances are there was nothing special or memorable for him of your interaction.
And here is how the point relates to the business of healthcare. The people who answer the phone at your health system’s call center—the big room with all of the phones in it—probably speak to a hundred different people each day, five hundred a week. Twenty-six thousand people a year. After a while, one call sounds like the next to the people answering the phones. The calls all blur together. The call center agent will not recall the date she spoke with one of your patients, or what she was wearing that day, or what she had for breakfast. It is sort of like the president remembering the person in any single photograph.
Now, what if we reverse the roles and look at the call from the perspective of the caller—the patient or the consumer on the phone. That caller, every caller, will remember every detail of that call. They will remember how long they were placed on hold, how many times their call was transferred, and how many times they had to call your health system. They will remember the date of their call, what they were wearing that day, and what they had for breakfast.
And if they had to call more than once, their ability to recall their experience will be reinforced.
People do not want to call your health system any more than they want to call Verizon. They call because they have to. They call because they have no real alternative to calling. One in four callers, no matter how good their experience during the call, will think about changing providers just because they had to call.
The bad news is that nobody in your health system knows what kind of experience any single caller had. They do not know because they do not ask. More people, patients and consumers, interact with your health system by phone every day, than in any other way. Most probably wish they did not need to call. Most hope they will not have to call again. And many won’t call again.
And if you are keeping score, that is a bad thing for you.
As a parent I’ve learned there are two types of tasks–those my children won’t do the first time I ask them, and those they won’t do no matter how many times I ask them. Here’s the segue.
Hospitals have a gazillion business systems. Every business system can include the following three things; people—doing things, processes—the way and order in which things are done, technology—whatever part of those things that may be automated. Two examples of business systems—ordering your meal in the drive-through lane at Burger King; open heart surgery.
Believe it or not, from a process standpoint, each of the hospital’s gazillion business systems can be sorted into one of two buckets—Easily Repeatable Processes (ERPs) and Barely Repeatable Processes (BRPs).
An example of an ERP industry is manufacturing which executes identical business systems thousands of times—clean the Pepsi bottle, fill the bottle with Pepsi, put on the bottle cap, and place the bottle in the box.
Healthcare, in many respects, is a BRP industry. BRPs are characterized by collaborative events, exception handling, ad-hoc activities, extensive loss of information, little knowledge acquired and reused, and untrustworthy processes. They involve unplanned events, knowledge work, and creative work.
ERPs are the easy ones to map, model, and structure. They are perfect for large enterprise software vendors like Oracle and SAP whose products include offerings like ERP, SCM, PLM, SRM, CRM.
How can you tell what type of process you are trying to incorporate in your effort to improve patient experience? Here’s one way. If the person standing next to you at Starbucks could watch you work and accurately describe the process, it’s probably an ERP.
So, why discuss BRPs and ERPs in the same sentence with patient experience? The answer is quite simple. Think of BRPs—barely repeatable processes—as those processes associated with HCAHPs; exception handling, unplanned events, and knowledge work.
Think of ERPs—easily repeatable processes—as those associated with all of the back office support processes patients and prospective patients have with the health system. Access processes. Those include:
Here is what is unique about a hospital’s ERPs:
Hospitals behave as though these processes have nothing to do with patient experience. Just because hospitals do not acknowledge the existence of or the importance these systems have on patient experience does not make them irrelevant.
True story—a Top 5 US hospital. A cancer patient between treatments who is experiencing the after effects of chemo calls the hospital to schedule a follow up exam. She spends almost three hours on the phone. She told me that because of that one event she will never recommend that hospital to anyone.
Now to the meat of the matter; money. Healthcare may argue that they are not in business for the money. While that may be true, they are not in business if there is no money. So let’s talk about dollars.
The taxonomy of 99% of existing patient experience business systems is that they are ineffective, unmeasured, and proving awful experiences at the places where people touch the health system—the phone and the web.
Ignoring these aspects of patient experience is no different than having your hospital’s CFO drive down the highway while pouring bags of money from the window.
What do you think?
People will tell you that health systems cannot sell them anything even though they have large marketing and business development departments. Patients are not sold healthcare by the health system, they purchase healthcare from the health system. Patients hold the power.
If you want to build your business stop trying to sell people your services. Instead, make it easy for them to buy your services. Become the health system that is easy to do business with.
Unfortunately, few if any health systems are doing that.
What would happen if a fifty-four hundred people (one person for every hospital) were standing together in a field, and they each took one step forward. The next month they did exactly the same, and so forth and so on, ad nauseum. The crowd would certainly have changed places, but relative to one another the individuals would all be about as far apart from each other as they were when they started. Not much would have changed, at least not much that was noticeable. To a prospective buyer all they can see is a lot of chaff and no wheat.
Now what would happen if one person—or hospital—decided to be innovative and did something disruptive and separated themselves from the crowd? What if hospital sprinted in a different direction? They came to a fork in the road and they took it.
With every hospital’s focus on HCAHPs, it can be argued that they are all moving across the field somewhat in lock-step. Now before anyone gets the notion that I am arguing that hospitals should stop focusing on HCAHPs that is not my intention. Improving HCAHPs is a good thing. Getting each hospital moving towards one hundred percent in all categories is a good thing. Sort of. Just remember, nailing HCAHPs is not the same thing as nailing patient experience.
With every health system taking one step forward on their goal to improve the patient experience of each surveyed patient, who then is responsible for moving the organization forward for improving the satisfaction of all patients?
Doing what every other health system is doing is not innovative. It will neither drive patient retention or referrals, nor will it improve the satisfaction of those people, patients and prospective patients, who visit the hospital via the web or by using the phone. It will also have little or no effect on those who were surveyed—they have already been discharged. It will also have a similar effect on those who were not surveyed.
Innovation is the application of new solutions to meet needs or changing market requirements. For innovation to work an organization must acknowledge a problem/opportunity. Like a 12-step program. Hi, my name is Paul and we have a patient satisfaction problem.
The health system that chooses to separate itself from the pack will recognize that most of an individual’s satisfaction with their interaction with the health system happens outside of the hospital’s four walls. It happens before they are admitted and after they are discharged.
I like to define it as follows:
The total quality of a person’s (patient & non patient) encounter is equal to the sum of the Patient’s Experience (HCAHPs) plus Patient Satisfaction (all of the other interactions they have with people, process, and systems.) If your health system has not totally reinvented those interactions in the last three years the access experience you are providing is well below what it could be.
New College, Oxford, was founded in 1379, hundreds of years prior to the invention of the I-Beam. The roof of the college’s main dining hall is supported by big oak beams, two feet square and forty-five feet long.
Wood has a number of characteristics. The characteristic most relevant to this discussion is that it rots.
About 100 years ago, entomologists were studying the beams in the roof and they noted that the beams were infested with beetles, thus eroding the integrity of the roof. Unfortunately for the college it was believed that all of the large trees from the old-growth forests had long since fallen.
As luck would have it, the college owned a great deal of land and actually employed its own forester. When the college asked their Forester about whether he knew of any large trees, the Forester replied, “I was wondering when you’d come asking.” It was discovered that when the college was founded, a grove of oaks had been planted to replace the beams in the dining hall when they became beetle-infested. This information had been passed down from forester to forester for more than 500 years.
Long term planning: Planning that involved the exact solution, not a series of ad-hoc fixes year-in and year-out.
When I built my home I did some long term planning as well. I had telephone jacks and Ethernet wired to every room in the home. That way, I would be able to make a call from any room in the home and have an internet connection in every room. About a week after we moved in to the house I learned about something called a wireless router. So much for my astute planning.
So, how does planning come in to play with healthcare providers? Or does it? Has anyone every used the terms planning and patient access in the same sentence?
Most health system call centers are nothing more than a big room with a lot of phones in them. And that is exactly how they function. There is no ability to support care coordination and back office functions. There is no single path to anywhere. There is no first call resolution. There is, however plenty of opportunity to call and call and call.
So, how would things differ if instead of the call center being just a big room with a lot of phones, someone had actually planned for what it needed to do? What if the goal was to provide care coordination and back office support? It might look something like this.
But until someone actually creates a plan and a design for supporting the most complex business system in your organization it will continue to be just a big room with a lot of phones.
But until someone actually creates a plan and a design for supporting the most complex business system in your organization it will continue to be just a big room with a lot of phones.
Point One. Heliocentric versus geocentric. Heliocentric—the planets revolved around the sun. Geocentric—the earth was the center of the universe and everything revolved around it. Copernicus. Early astronomer, pretty smart guy—he got it right.
Point Two. Patient experience. The hospital is the center of the universe and the patients revolve around it. Where is Copernicus when we need him? What about a patient-centric model?
Four out of five hospitals do not have a patient experience strategy. Of those 20 percent that do, most, if not all of them, do not include anything outside of HCAHPS.
There are several fatal flaws with the hospital-centric model of patient experience. Improving HCAHPS scores is not the same thing as improving patient experience. One strategy involves improving a set of numbers, the other involves improving experiences.
Here are the flaws around what most hospitals are doing:
The experiences of outpatients are ignored—surveying them doesn’t count; we already established that with HCAHPS.
The experiences of all prospective patients – the largest group of stakeholders – are ignored. Definition of Prospective Patients—everyone who has ever been to your web site, called the hospital, parked in the garage, eaten in the cafeteria and driven past the billboard advertising the hospital’s urology practice.
The hospital-centric patient experience model requires hospitals to try to apply a fix for every patient experience, patient by patient, day after day. One hospital fixing thousands of patients’ experiences. Shampoo, rinse, repeat. Since the patient is no longer classified as a patient when the fix is applied, whose experience is the hospital attempting to fix?
The patient-centric model of patient experience centers around one patient, one person. It is designed, planned and thought through. A patient, like a customer, should be able to carry the hospital around on their iPad. That person should be able to accomplish everything they need to with the hospital, with the possible exception of a hip replacement, the same way they can accomplish everything they need to with Amazon.
The following graphic shows the lifecycle of someone’s experience with a hospital. The most noteworthy aspect of the graphic is that only the green circle represents a person’s time in the hospital. The blue circles represent all of the other interactions someone has with the hospital.
Patients only spend a small fraction of their time in the hospital. Hospitals only spend a fraction of their time understanding the totality of someone’s experience.
Since most hospitals do not have a working definition of patient experience, I like to use this definition: TQE—the Total Quality of a person’s Encounter with the hospital is equal to the sum of their HCAHPS scores plus all of the nonclinical patient touch points. This definition parallels The Beryl Institute’s definition of the patient experience – the sum of all interactions, shaped by an organization’s culture, that influence patient perceptions across the continuum of care. Using these definitions as guides in their own organizations enables healthcare leaders to truly keep the patient at the center of their universe.
A remarkable experience happens for every person, every time, on every device.
My favorite thing about healthcare is having witnessed it up close and personal both as a cancer patient in the 80’s and as the survivor of a heart attack seven years ago.
I was fortunate enough to have testicular cancer before Lance Armstrong made it seem kind of stylish. Caught early, it’s one of the most curable cancers. As those who’ve undergone the chemo will attest, the cure is almost potent enough to kill you.
I self-diagnosed while watching a local news cast in Amarillo where I was stationed on one of my consulting engagements. As we were having dinner, my fellow consultants voted to change the channel—I however had lost my appetite. I went to my room, looked in Yellow Pages—see how times have changed—and called the first doctor I found. This is one of those times when Never Wrong Roemer hated being right.
So, yada, yada, yada; my hair falls out in less time than it took to shower. A few more rounds of chemo, the cancer’s gone and I start my see America recovery Tour, my wig and I visiting friends throughout the southeast. If I had it to do over, I would go without the wig, but at twenty-seven the wig was my security blanket. I don’t think it ever fooled anyone or anything—even my house plants snickered when I wore it around them.
I owned a TR-7 convertible—apparently it never lived up to its billing as the shape of things to come, more like the shape of things that never were. My wig blew out of the convertible as I made my way through Smokey Mountain National Park. I spent twenty minutes walking along the highway until I spotted what looked like a squirrel laying lifelessly on the shoulder—my wig.
The last stop on my tour was at a friend’s apartment in Raleigh. Overheated from the long drive and the August sun, I decided to take a few laps in her pool. I dove in the shallow end, swam the length of the pool, performed a near-flawless kick-turn and eased in to the Australian Crawl. As I turned to gasp for air, I noticed I was about to lap my hair. I also noticed a small boy, his legs dangling in the water, with a look of astonishment on his face.
My ego had reached rock bottom and had started to dig. Realizing my wig wasn’t fooling anyone but me, I had one of those “know when to hold ‘em, know when to fold ‘em moments” and never again wore the wig after learning it was such a poor swimmer.
Do you get those moments, or get the little voice telling you that your EHR that the users would rather enter patient data on an Etch-A-Sketch? It’s okay to acknowledge the voices as long as you don’t audibly reply to them during meetings—I Twitter mine.
Sometimes the voices ask why we didn’t include the users in the design of the EHR. Other times they want to know how that correspondence course in project management is coming along. It’s okay. As long as you’re hearing the voices you still have a shot at recovery. It’s only when they quit talking that you should start to worry. Either that, or try wearing a wig.
His colleague asked the physician, “How is it that you are able to see tens times as many patients each day as the rest of us?”
“You guys spend too much time meeting with patients and asking them questions. I do Facebook Care. I just look at their picture on Facebook, and if I don’t see anything wrong, I move on to the next one.”
“That is not the way it works. You have to observe them. You have to ask questions, and run some tests, and then ask more questions. That is the only way to know how they are doing. Where did you go to medical school?”
“I didn’t,” came the reply.
In another part of the hospital I overheard this conversation.
“What is going on with the call center?”
“The call center? What is it?”
“It’s a big room with a lot of phones, but that’s not important. How is it running? How well are people able to access us?”
“Everything is fine.”
“How do you know?”
“Because there is a big room with a lot of phones in it and I can hear them ringing?”
I interjected myself into the conversation. “Where did you go to patient access school?”
“I didn’t,” came the reply.
That is one way to know how well patient access is functioning in your organization—if the phones are ringing, everything related to patient access must be okay.
Here is another way to assess patient access. Go into the big room, the one with a lot of phones in it.
Here is what every health system executive should know about their patient access system. Let’s assume your system receives one thousand calls a day. On average, of those thousand calls:
Patient access may be the single largest business system in your entire health system. A business system has three components; people, processes and technology. Each component must function well for the system to function.
Now, pretend you are a physician diagnosing the patient access function, and do what they do when they see a patient; ask questions, observe, run tests. Go through a process of discovery:
Unless you have already run this diagnosis you have no way of knowing how dysfunctional patient access is in your health system.
I have never seen your health system, but I can tell you that I do not need to see it to know that it is in trouble. And when your access business system is in trouble patients leave. And they don’t just leave, they run for the exits and they tell others why they left.
A colleague of mine was finishing her cancer treatment at one of the top three hospitals in the U.S. She called to make a follow up appointment. It took her three hours on the phone to get her appointment.
She called me just to tell me about her frustration with that hospital. And she concluded her call saying; “I will make it my mission in life to tell everyone I meet not to go to that hospital.”
The time has come to diagnose the health of your patient access business system. And after you diagnose it, write a prescription to fix it.
I thought I would close out the week sharing a few thoughts about one of my favorite subjects, business meetings. It is difficult to find a good meeting—one that starts and ends on time, one with an agenda, and one with someone who knows how to run a meeting.
Sooner or later, you have to say something, just to appear interested, and to keep someone from saying, “We haven’t heard from you, what’s your take on the fact that aliens appear to be using the men’s room after hours?” You must keep your head in the meeting enough to make sure you don’t shout out something inane like “You sunk my battleship.”
Most times you can slide by, by just throwing your support behind someone else’s comment. “Well said Sally.” Usually someone who was dealt a pair of twos in the looks category will ask you a trenchant question in a dullard’s voice—a voice that tells you that the person speaking won’t be invited to join Mensa any time soon—why you agree with Sally. In that case, your best defense is to use words with three or more syllables. It is for that very reason I keep a jar of big words next to me, and interject them as needed. If you can spit out aberrant and nonplussed in the same sentence, chances are good they will leave you alone. The less others understand about what you are saying, the less likely they will be to question you for fear they will appear stupid.
I have many of the same issues with presentations, but at least you have slides to look at.
So, back through the looking glass, back to healthcare. The field of espionage uses the expression walk back the cat. It means to trace some thing or some event backwards to see what can be learned.
Pick a number between one and ten and throw in two decimal places just for fun. Now tell the person next to you what your number means or what their number means. Kind’a tough to do.
It may not mean anything. Patients who complete a survey, who rate each question on a scale from one to ten, are going through the same exercise, they are picking a number. What does their number mean?
What does the average of all of the numbers, or their median mean? Sorry for the double-entendre. What does it say for those whose scores are two standard deviations away from the mean?
There are two ways to look at improving patient/customer experience. One way, the way most organizations go about it is to tailor it, person by person, to the requirements ofeach individual. Since you can never get to each person to assess their needs, this approach normally fails.
The right way to create a patient experience strategy is to define the requirements of everyindividual by defining the needs and expectations of a single global patient and a global prospective patient.
Now try coupling that approach to this definition of patient experience—a remarkable experience for every person every time on every device.
Anything less should be unacceptable. After all, what part of that definition is an organization willing to weaken? Each weakening means a loss of patients. Why bother having a marketing and business development group to bring patients in through one end of the funnel if only to have them quickly exit at the other end because of a less than remarkable experience?
Instead of offering a remarkable experience, should we be willing to settle for a pretty good experience? Should the remarkable experience be available to everyone, or just to most of the people. Every time, or most of the time? On the phone, a laptop, and a tablet, or just in the hospital?
The existing theory is that all patient experience can be managed through the looking glass of HCAHPs. In order for that theory to work, the theory must become fact. If it is not a fact then the only alternative is that the theory is wrong.
If you test the theory and the results do not match the theory, do not blame the results, or change how you interpret them. Change the theory.
Whether one is running at windmills as a quixotic muse, or trying to bisect an elephant with a licorice whip, to anyone observing those actions it makes no more sense than having a lint collection.
Example 1: Let us say that someone walks into a nail salon and requests a manicure and a pedicure. The salon’s owner says “We only do manicures here. You have to go across the street for a pedi.”
You get the manicure, and as you are leaving the owner asks you to complete a survey about your experience with her establishment, and then she asks you to recommend your friends.
Example 2: You call the company who provides your cable television, your internet, your wireline, and your mobile service to tell them that your cable is out and that you have a question about your wireless bill.
As you wait on hold you hear the message repeated over and over for forty-five minutes that this call may be recorded for quality purposes. When you are finally afforded the opportunity to speak with a hominid about your cable outage you are told to call the cable service number. When you ask about your mobile bill you are told those questions can only be answered between 8 AM and 5 PM Mondays through Fridays. As you are about to explain that it is 10 AM on Tuesday the operator disconnects the call.
Within a minute you receive an email from the firm asking if you would complete a brief survey about your experience with them
Example 3: (stop me if you see where this is headed) It is 6 AM. You are going to be charged for parking. You have passed through a lobby that is as ornate as anything in one of Dubai’s finest hotels. You and the lemmings are seated in the admissions waiting room alone. Each of the admittors (first-person singular present passive indicative of admittor–I had to look that up) is sipping from their mocha cappuccinos. You are not because you have not been allowed to have anything to drink since the last republican administration. As you sit and wait for your turn to be admitted you are reminded of the last time you were at the DMV to have your driver’s license renewed.
A single television, which seems to be tuned to al Jazeera, is suspended overhead. As there is no wifi, your only other option for killing time is the copy worn of Highlights magazine announcing the upcoming 1969 moon landing.
You complete the admissions process, finally. You ask to receive a copy of the hospital’s customer experience survey, an opinion form, or whether they have a comments box. Check D—none of the above. When you ask why you are told, “Mister this is a hospital. We make you better. That is the only experience we care about, and it should be the only one you care about.”
As the anesthesia enters your blood stream, instead of counting backwards from infinity, you are left wondering why you couldn’t self-admit the night before using your iPad.
Example 3 could also been an example of someone trying to schedule an appointment online or through the call center. It could have been someone requesting the medical records. It could have been someone trying to understand Medicare. It could have been someone trying to pay their bill. It could have been someone deciding where to buy healthcare. It could have been someone seeking a second opinion.
What hospitals do not understand is not that it could have been all these someone’s…it was and it is. Every day more people ‘visit’ your hospital online and on the phone than walk through the Dubai lobby, and nobody is asking them about their experience. Nobody knows what great patient experience looks like; nobody’s ever seen it. But they sure know what it is like trying to access their provider.
A remarkable experience every time for every person on every device.
I may be wrong but I doubt it.
Pale Rhino Consulting 