What is Healthcare’s Black Hole?

The temperature was in the mid-nineties.  Nine miles into my run I was approaching the crest of one of the many bridges that crossed the Clackamas River near Portland. 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.  (Getting older sucks, but it’s better than the alternative.)

To my surprise, an Oregon state policeman kitted out smartly in his pressed uniform and wide-brimmed hat, pulled alongside me. He rolled down the car’s window. “What are you doing on my bridge?”  He asked from the cool confinement of his air-conditioned patrol car.  There was an undisguised tone of concern in his voice. To hear what he was saying I paused Roy Orbison’s Running Scared and I removed one of my earbuds.

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 he had any ID to prove that he owned the bridge, but he did not look like he was in the mood to play games.

“Are you okay?” He asked me.  “You don’t look okay.”

“I’m fine. Why did you pull me over?” I asked. “Was I running too fast?” He was not amused by my attempt to engage him in meaningless banter.  “I just heard on the radio that a guy looked like he was ready to jump off my 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 my 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 of the guardrail to stretch my hamstring.

Eighty feet below me a small armada of boats had dropped anchor and the boaters appeared to be having impromptu tailgate parties in the middle of the bay.  Everyone was looking up at me, and some appeared to be filming, so I waved. I heard a few of the boaters yelling for me to jump.

I also heard the thwump-thwump of a television news helicopter as it hovered overhead, its parabolic microphone pointed in my direction. (I embellished my story a little to make for a better blog, but it’s my blog so I can write whatever I want.)

“Take your leg off my guardrail,” he ordered, “and back up slowly.” “I was about to call for a police helicopter and rescue divers. Are you sure you are okay?”

I was going to ask him if his helicopter would give me a ride home, but he didn’t look like a ride home kind of guy. If I continued across the bridge, my home was only two miles away.  If he did not let me cross the bridge 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.

Segue.

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.) There’s no place like 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 the services I could schedule. The final webpage told me that if I wanted to schedule an appointment I should call the hospital Monday through Friday between eight A.M. and five P.M.

The website’s scheduling web page should have included a 24-point, bold disclaimer stating, You can’t do that from here. Like trying to cross the bridge.

Healthcare is the only industry that requires you to have a phone to do what you want to do.

 

Healthcare: Please Don’t Make Me Call You

Nowadays you can’t swing a cat without hitting someone who has a newer and better idea about how you can fix your organization. More often than not, those ideas include the word design: user design and human-centered design are two of the culprits.

And that is the problem. Every business process in every firm is the outcome of human-centered design. Somebody—a human—designed it. And chances are very good that they did not design it well.

Instead of thinking, ‘How would I design this?” executives need to be asking, “How would other people—humans—want to use this process?”

To be effective at what they do, firms need to go from user design to user-centered-design. They need to go from human design to human-centered design. When talking about what makes one business more effective than another business, one word, centered, makes all of the difference.

I’ll use healthcare to illustrate the point, but the same issues apply elsewhere.

If you have ever called your payer or your provider, you know what I am talking about. Whoever built the call center you called spent way more attention selecting the color of the carpeting that was installed than they did figuring out how to solve business problems.

The same logic, minus the carpeting, applies to their websites.

Nobody ever sat down with a patient and asked, “What do you want to do, and how do you want to do it when you contact us?”

Neither did CMS when it came up with its list of what constitutes a good patient experience.

If you are a healthcare executive, consider doing this. Sit down with a patient, and have the following conversation.

Executive: “What do you want to do when you call us?”

Patient: “I do not want to call you.”

You can take it from here. If you get stuck, let me know.

Would CX Be Better If You Spoke British?

I have no segue to offer you in this missive. What follows are the incoherent musings of my drive-by-mind. If you know how to play Guitar Hero, the next two minutes of your time may be better spent doing that. If not, let’s just agree to tough this out together.

I wrote a few weeks ago that I had auditioned for a play and that the theater for which I auditioned is going to pay me to accept the part. It’s okay to laugh…I find it equally amusing. Maybe this consulting thing I’ve been doing for the last thirty years has been no more than a placeholder until I discovered what I wanted to be when I grew up.

Having said that, a week from Saturday I am auditioning for another play, a British comedy. Between now and then I have to develop a posh English accent. Whilst versus while. Let’s have a cuppa tea. I have an MBA from a rather up-market university. None of the people with whom I graduated are spending their downtime memorizing Monty Python monologues in the hope that a director in London’s West End will discover them.

Don’t try blogging on your own, friends. I am a trained professional and I am accustomed to bearing the slings and arrows that result from trying to piece together unrelated sentences and worrying about whether any of those sentences end in a preposition.

Time passes. Yada, yada, yada.

And so, as my plane taxied, the stewardess—forgive me, but I was born before being politically correct was a requirement to maintain one’s American citizenship (just in case, I am applying for a green card)—had just finished making her pre-flight safety announcement. Her facial expression suggested that someone should have given her a chew toy.

My tie was all akimbo—that is the wrong usage of the word ‘akimbo,’ but having been a math major, I threw grammar aside simply because I like the word. My seatback was reclined to the level of an all-inclusive Mexican resort lounge position. My tray table was down. My laptop, which was on said tray table, was performing blockchain aerobics. My Bose headphones were pumping out Meatloaf; not as a main course.

If Dylan Thomas was/were (I don’t know which word is the correct usage of the verb.  Was and were are in the past tense, but they are used differently. Was is used in the first person singular and the third person singular (he, she, it). Were is used in the second person singular and plural (you, your, yours) and first and third person plural (we, they)) seated next to me on the plane, Dylan would have said that I was not going gentle (you and I both think that the correct grammar should be ‘gently’) into that good night. However, Sir Thomas wasn’t an English major.

Nor was I. I won’t fault you if you quit reading at this point. I probably should have done all of us a favor and quit writing.

Demurely, I raised my hand and asked the stewardess, cum flight attendant, “Do you mind repeating that bit again about how to buckle the seatbelt? I fly every day, but I never seem to understand the part about inserting part A into part B. Do I put A into B, or do I insert B into A?”

Her head exploded. And that is precisely why I asked the question.

Segue.

You name the industry and I will tell you how bad its customer experience is. Each of us would rather remove our own wisdom teeth rather than call any company’s customer service. Customer experience—healthcare calls it consumerism—is especially inept in healthcare.

When it comes to consumerism or customer experience, what the people who are trying to improve your organization’s customer experience lack in experience, they make up for it with their inexperience.

What would you do if your bank required you to call them every time you wanted to do anything—pay a bill, make a deposit, change your address? You would change banks without batting an eye or worrying about whether the other bank offered free checking. You would not care if the bank was offering a free toaster. You would sacrifice free checking for an easy button.

Healthcare doesn’t offer an easy button.  And to make up for its lack of convenience, nor does it even offer a toaster. Make an appointment, call. Set up a payment plan, call. Talk with a doctor, any doctor, or even someone who plays a doctor on television, call.

However, if you want to make a donation, pay your bill, or learn what time the gift shop opens you can meet those needs online.

Healthcare has created a codependency between the callers and the person answering the calls. Both parties are in agreement that whatever conversation that takes place during the call will be unsatisfactory to both parties. “You don’t want to be calling us, and we don’t want to be talking to you.”

Nobody, or at least almost nobody wants to call your organization. Ever. And how does healthcare address that issue?  Healthcare makes you call. It makes everyone call. Every time.

The World’s Best Customer Experience: The Tuna Paradox

Sometimes you have to get creative and sometimes you just have to manipulate someone to get the level of experience you want. Saturday required me to do both.

I arrived at the diner at 10:30 that morning. I scanned the menu and realized I wasn’t very hungry. The waitress asked for my order. “Toast and tea,” I said.

“We don’t just sell toast,” she replied. I began to count the number of items on the breakfast menu that came with toast—I pointed out that there were 16 of them. “Yes, but you have to order the item. We’re not going to just sell you toast.”

The gauntlet had been tossed rudely at my feet. I could leave or I could accept the challenge. I chose not to leave. I did, however, notice that the lunch menu offered a tuna sandwich that was less expensive than any of the breakfast items that came with toast.

“May I have the tuna sandwich toasted?”

“I suppose we could toast it,” she told me. “What comes on it?” I asked her. “Tomato, lettuce, and sliced pickles.” I began to reel her in. “Okay, let me have it without the pickles.” She made a notation on her pad. I aimed that meant she wasn’t able to simply memorize such a complex order and tell the guy behind the counter. Apparently, this evening’s Mensa meeting would require one less chair.

I eyed the toaster. “Come to think of it, hold the tomato and the lettuce.” “So, you want just the tuna sandwich?”

“Toasted,” I reminded her. “One more thing, can you make the tuna sandwich without the tuna?” Game, set, and match!

While I waited for my toast I also had my most enjoyable customer experience ever although it was not with a firm anyone would ever associate with providing good or even fair customer experience.

I had received my bill from Comcast for cable television. It took less than five minutes to learn that I could subscribe to YouTube TV, watch all of the channels I like to watch, and save beaucoup money. And so I called the Mothership. I was able to speak with someone after only twenty minutes of prompts and being on hold. A digital message informed me that my call was important and that it was so important that Comcast may record it for quality purposes.

Maybe they would learn something.

“How much would it cost if I canceled the cable and just kept the internet?” I kid you not…eleven minutes passed while this purveyor of digital services tried to Devine the answer to my question.

“Do you have a relative who works at a diner?” I asked him. He did not understand my question, and rather than taxing him further, I made the following remark; “You sell two things, cable and internet. I have cable and internet. If you subtract the cost of the cable, what is the price of the internet?” A tuna sandwich without the tuna, I wanted to tell him.

When he couldn’t do the math I hung up the phone and ate my toast. The toast was worth every penny I paid simply to have gotten my way.

And so the great experience to which I had referred was earlier today when I walked into the Comcast office with a box containing my DVR devices and remotes. I canceled my cable service. I felt so good canceling Comcast that I was tempted to resubscribe just for the pleasure of canceling it again.

I should mention that I also learned that I could get internet for less than half of the price Comcast was charging me.

And so I called the Mothership’s customer service line again and I said, “I subscribe to your internet service. What would my monthly bill amount be if I canceled my internet service?”

How To Recognize Awful Experience

I finally had my chromosomes mapped. It should not come as a big surprise when I tell you that I lacked the chromosome for patience and had a duplicate of the chromosome that is most closely associated with cynicism.

Nota bene. I am on my eighth American Airlines flight in the last two weeks. Each of them has been delayed by at least an hour and a half.

Water off a duck’s back. For some, perhaps. But, I’m not your average mild-mannered duck.

And so on the last of my eight flights I pulled out two sheets of paper, one sheet for each side of the plane. Across the top of each page I wrote, “List three things that you would do if you were an executive of American Airlines to improve the flying experience.”

And off they went to Row 1, seats a through C and Row 1, seats D through F. By the start of Row 4 I had received a request for more paper. I hired a small child who was seated across the aisle from me to be my courier. Back and forth he went, dispensing blank sheets of paper and retrieving the completed sheets. On his second trip forward his return trip was delayed.

“What took you so long?” I asked.

“A bunch of people wanted to make videos of their experience,” he told me. “And I had to show someone your age how to Instagram their trip.” (My age?)

I looked up and saw a flight attendant marching posthaste towards me. She was carrying several sheets of paper. The ammonium nitrate was about to hit the oscillating air device.  I gave her my best smile and a wink.  She looked me in the eyes and said, “The captain asked if he was permitted to share his recommendations.”

The wink gets them every time.

Flying.  Bad experience.  ‘Nuff’ said.  The blog could end here.  Healthcare reform could end here.  Neither one will happen.

Most airlines offer two types of seats; first class and no first class – steerage.

First class exists for only one reason—to let the rest of us know that we are not in it.  Airlines hang a shower curtain between first class and coach.  They do this to make it clear to those of us in the bleacher seats that everything beyond the curtain is off limits.  But they do make passengers flying coach walk through first class to get to their seats.  Now each coach passenger has a barometer to measure just how bad their experience is.

“Don’t even think about storing your bag there,” she notifies me.  “This bin is reserved for our first-class passengers!”  Blocking me with her body, the flight attendant turns to the person in seat 2A and asks “May I hang your jacket, sir?  Would you mind if I refill your Crown Royal?  Be sure to leave room for dinner—we’re serving steak and lobster tonight.”  I wished I had purchased the thirty-dollar bag of Gummy Bears.

The bad experiences of coach class are particularly bad simply because first-class exists.  If there were no first class, flying coach would not be so a bad because we all suffer together. Southwest Airlines figured that out.  They do not offer first class.  And despite that, they are always among the highest rated airlines for customer experience.

Healthcare patient and customer experience.  How good was yours?  The scoring is binary —a 1 or a 0.  You either sat in first class or you sat behind the shower curtain.  Did your healthcare experience compare to having surf-and-turf, or did it make you wish you had bought the Gummy Bears?

Bad customer experiences are not insoluble.  Very little is.  For most companies, bad customer experiences are simply a failure of imagination.  For providers, their failure of imagination comes at a high price: poor care management, lost patient acquisition, and poor patient retention. And if that is not a real mess, it will do until the real mess comes along.

Just so you know, none of us likes flying coach.

His Name Was Ed

You don’t have to read this. But I had to write it.

He was a man nobody would write about other than someone to whom he meant the world. One of his final requests was to be buried alongside other veterans in the national cemetery in Florida.

He served in Japan as part of the occupation force after World War II. He never faced combat. He wasn’t an officer. Nor was he a corporate executive.  He wasn’t a first responder. He didn’t run into burning buildings. He wasn’t thought of as exceptional.

He was a civil servant. After leaving the military he worked for thirty-five years at one of the federal agencies in Washington D.C. It was an agency whose name the employees never mentioned.  In fact, its employees were simply told to tell others that they worked for the Department of Defense.

He was my dad.

On those days in elementary school when the children were told to talk about what their fathers did for a living, I didn’t have much I could tell about my dad. I thought about lying and saying my dad was a pilot or that he played baseball. But my friends and I collected baseball cards and none of them had ever seen my dad’s picture on a baseball card.

I only knew three things about what my dad did for a living. First, every so often the FBI would talk to our neighbors and they would ask them if they knew what my dad did.  The only acceptable answer was ‘no.’ Secondly, although he carried a briefcase to and from work—the briefcase only contained his lunch. He wasn’t allowed to bring any documents home.

Oh, and he was fluent in Russian. Fluent in Russian at a time when my friends and I and millions of other students were taught what to do in the event of a nuclear attack.  An attack by the Russians—his Russians.  We practiced ‘ducking and covering’ under our desks. Call me crazy, but I never held much belief in the efficacy of ducking and covering.

Even though when I was in college I held a top-secret security clearance, to this day I still don’t know what he did but that has never stopped me from embellishing the narrative of his life. I may have occasionally implied that he left rolls of microfilm tucked behind a loose brick in the southwest corner of the wall of the Metropol Hotel across the street from the Kremlin.

I prayed on the plane. Hard. My only request was that he would still be alive when I arrived at the hospice in Florida from the airport. ‘He keeps asking if you’re here,’ my mother had told me prior to my flight.  I shared my concern that I would arrive too late. My friends told me that he would wait for me to arrive.

And he did wait. I held his hand and told him I loved him. With eyes that were no longer seeing he brought my hand ever so slowly to his face and he kissed the back of it and then he pressed it against his cheek. I prayed with him.  I’m not sure that he heard the prayer, but I knew God heard it. I leaned close and I told him that it was okay for him to go.

A veteran of the Vietnam War asked permission to enter my father’s room. In remembrance of my father’s service, the veteran presented me with a star that had been cut from an American flag. He gave my mother a certificate acknowledging my father’s service. The veteran turned smartly and saluted the unseeing man who lay motionless in the bed and said, “Soldier, on behalf of a grateful nation, thank you for your service.” That was as ‘proud to be an American, goosebumps moment’ as I ever had.

My dad died this morning. His death won’t be written about. It won’t be reported on television. Flags will not be lowered to half-mast.  His death will not create a Butterfly Effect. The world will not skip a beat.

My heart did.

My dad was the most honest and decent person I ever met. I never heard him swear. I never saw him drunk. I never saw him deliberately choose to do something that was not right.  Everything that is good about my character, my faith, my integrity, and choosing to do what is right, I got from my father. My failures and failings are of my own making.

They say you are not really dead until no one ever again says your name. This Father’s Day, if you can, talk to your dad. When my three children think of me I hope they see my dad. His name was Ed.

A healthcare footnote:

The week before he entered the hospice he entered the hospital. His pulse was 120. They gave him an MRI. The authorization form asked him to indicate whether he had any kind of dental plate. He wrote that he did.

The hospital performed the MRI and took my father back to his room. They were going to discharge him that afternoon. But he refused to eat and drink and take his medicine. He refused for 15 hours.  Instead of telling the nurses why he refused he made loud guttural sounds. And when he refused he kept pointing to his mouth. Finally, my mother looked in my father’s mouth and she saw that the tip of his dental plate was barely visible in his throat.

He had aspirated the plate during his MRI, the very same plate that he had told them about on the authorization form. They took him to surgery. The next day there was no discussion of discharging him. The hospital was now recommending that he enter a rehab facility. My mom, who is also 89, spent the day visiting rehab facilities. She found one close to their home and began the admitting process.

Two more days passed. Gone was the discussion of moving him to a rehab facility. His doctors now agreed that my father, the man with a high pulse, should be moved to a hospice.

When he arrived at the hospice, his pulse was normal. If that sounds cynical, that was my intent.

 

My Healthcare Consumerism Podcast

The Myers-Briggs personality profile test concluded that I am an INTJ—the ‘I’ means I am an introvert. The NTJ means I make Napoleon seem like a pacifist. Anyway, I think I mentioned that I moved to Portland, Oregon in January. I’ve learned a lot about mosses.

Wanting to connect to my new community, I, the introvert, decided to audition for the play Inherit the Wind. I should mention that the last time I was on stage was in college. I auditioned for a play my junior year in high school. Because I didn’t get the lead I quit. I got the lead my senior year.

The audition in Portland required me to perform a monologue and a song. As a person of unlimited hubris and believing that I am not an introvert, I chose to sing ‘Bring him home,’ from Les Mis—if you are going to make a fool of yourself you might as well shoot the moon.

For the monologue I memorized three well-known courtroom scenes; Al Pacino’s closing argument in And Justice For All, Jack Nicholson’s testimony in A Few Good Men, and Matthew McConaughey’s closing argument in A Time to Kill. Go big or go home.

The result of my audition? Not only did I get a part, not only did I get the lead role, they are going to pay me to perform. The world gets curiouser and curiouser.

My days of being an introvert are over.

No segue.

Healthcare Compliance Solutions invited me, as a subject matter healthcare consumerism expert, to be interviewed for a podcast.  In the podcast, I discussed the issues around how to improve consumerism, access, and engagement for all health stakeholders to drive accountable care, population health, and wellness.  Here’s the link: