Let’s do a quick survey.

Have you ever flown on American Airlines? If so, how would you rate your experience?

• Can’t wait to fly them again
• The only thing that could have made it worse was if the pre-flight music was Celine Dion’s latest CD.
• I would gnaw off my leg before I would fly them again.

Same questions for US AIR.

Let’s try another question.  American and US AIR are in the process of merging. Would you expect your experience with the merged entity to be (A) better, (B) the same, or (C) worse? Hint; (A) and (B) are not viable choices.

Permit me to raise similar questions with some of our other favorite industries. Insurance—pick your two favorite payers. Telecommunications—Comcast and Verizon. I would rather stick a fork in my ear than have to call any of these firms. In fact, I put off calling these firms, often to my detriment.

Why? Because the experience is painful and unproductive. Because it is an exercise in futility. Because there is nothing I can do to control the experience.

Now let’s apply this reasoning to healthcare. American and US AIR. The experiences of the combined firms becomes worse than your experience of any one of the original firms; a fact that is almost unfathomable given how poor the original experiences were. People are left trying to answer the question—how could the experience possibly have worsened?

At least those airlines have automated the bad experiences they provide their customers. You can have a bad experience online and you can have an equally bad experience on the phone. At least those firms employ CRM systems for inbound calls to at least given the agent on the phone a way to try to be helpful.

Hospitals do neither. None of their customer experience processes are automated. There are almost no tasks a patient or customer can do on a hospital’s website other than read about the hospital.  None of the people who answer the calls to the hospital have the tools they need to improve the experiences of the callers. With an airline you have the luxury of having a bad experience 24 X 7.  With most hospitals you can only have the bad customer experience Monday through Friday between 8 AM and 5 PM.

Now suppose the hospital is part of an IDN, or has acquired another provider, or has a few clinics. How does the customer experience of the combined entity compare? When you combine one experience that was never designed to be exceptional with another experience that was never designed to be exceptional, would you expect the combined experiences to be better or worse?

The business experiences people have with hospitals require individuals to talk with a hospital employee either face-to-face or by phone.  The three biggest problems people have with hospital experiences is that the experiences:

• Are not controlled by the individual
• Are not automated
• Are not available 24 X 7

Each of these problems can be corrected. All that is needed is for someone to decide to do it.

Until then, call one of the airlines and go somewhere nice.

So I’m making dinner the other night and I’m reminded of a story I heard a while back on NPR. The narrator and his wife were talking about their 50 year marriage, some of the funny memories they shared which helped keep them together. One of the stories the husband related was about his wife’s meatloaf. Their recipe for meatloaf was one they had learned from his wife’s mother. Over the years they had been served meatloaf at the home of his in-laws on several occasions, and on most of those occasions his wife would help her mom prepare the meatloaf.

She’d mix the ingredients in a large wooden bowl; one pound each of ground beef and ground pork, breadcrumbs, two eggs, some milk, salt, pepper, oregano, and a small can of tomato paste. She’d knead the mixture together, shape into loaves, and place the loaves into the one-and-a-half pound pan, discarding the leftover mixture. She would then pour a mixture of tomato paste and water, along with diced carrots and onions on top of the two loaf, and then garnish it with strips of bacon.

He went on to say that meatloaf night at home was one of his favorite dinners. His wife always prepared the dish exactly as her mother. One day he asked her why she threw away the extra meatloaf instead of cooking it all. She replied that she was simply following her mother’s recipe.  The husband said, “The reason your mom throws away part of the meatloaf is because she doesn’t own a two-pound baking pan. We have a two pound pan. You’ve been throwing it away all of these years and I’ve never known why until now.”

Therein lays the dilemma. We get so used to doing things one way that we forget to question whether there may a better way to do the same thing. Several of you have inquired as to how to incorporate some of the patient experience strategy ideas in your organization, how to get out of the trap of continuing to do something the same way it’s been done, simply because that’s the way things are done. It’s difficult to be the iconoclast, someone who attacks the cherished beliefs of the organization. It is especially difficult without a methodology and an approach. Without a decent methodology, and some experience to shake things up, we’re no better off than a kitchen table amateur (KTA). A KTA, no matter how well-intentioned, won’t be able to affect change. Without them the end results would be no more effective than sacrificing three goats and a chicken.

So, here we discuss how to disrupt patient experience, how to find a champion, and how to put together a plan to enable you to move the focus to developing a proper strategy, one that will be flexible enough to adapt to the changing requirements. But keep the goats and the chicken handy just in case this doesn’t work.

I’m sure you have seen the dance when someone in your organization expresses an idea about how to change something that most people do not think needs changing. It looks a lot like two dogs sniffing around each other to see whose top dog.  People like being on the solid ground that comes with maintaining the status quo, afraid that if they step off they will be on a greased slope, or even worse that they will be sent to the penalty box to listen to old ABBA songs.

A gentleman in my meeting was pointing at something in my presentation with all of the trepidation of a new geography teacher trying to locate Burma on an outdated map. I knew how he felt. Sometimes l like to leave a trail of breadcrumbs for my audience to follow as I try to make my point. 

But we have all had times where we would have been served better had we left a trail of croutons instead of breadcrumbs. (Croutons are larger, making it easier for people to follow them.) Those are the times when you feel it would be easier to slip a hippo through a clarinet than to slide a fresh idea between two synapses, like trying to explain cholesterol to a Big Mac.

So there I was in the meeting laying out my vision for the hospital of the future, one in which patients would carry their hospital around on their iPad the way people carry around Amazon today. One member of the audience asked me if I had ever seen such a hospital. I replied that I had never seen such a thing, but then again I had never seen my pancreas, yet I knew I had one.

There is no technical reason why someone cannot interact with their hospital online to accomplish all of their business needs. There is no technical reason why someone cannot register, schedule, admit, manage their discharge, educate themselves, monitor their health, set up a payment plan, refill a script, or file a claim.

The only thing preventing this is that nobody has stood up and said “Let’s do it.”

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!”

Foolishly I hoped she 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.  (I thought I would reference Brazil since we just completed the World Cup.)

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.

Let us take a minute to define who and what we are talking about when we use the word patient.

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

I believe there are five patient personas, each of which had a question they need to answer:

• Prospective patients
• Outpatients
• Inpatients
• Discharged patients
• Former patients

Prospective patients: Will I buy healthcare from this institution

Outpatients: Involved with the institution—Will I but more healthcare from this institution?

Inpatients: Committed, at least for the moment to the institution. (The chicken is involved with breakfast, the pig is committed.)  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 only personas for which the hospital knows the experiences of a particular persona are the inpatients. And what do they know? Do they know your experience if you happen to be the inpatient? Of course not. The only thing they know about the experience of an inpatient are the aggregated experiences as those experiences relate to the HCAHPS scores of a sample of inpatients several months after those people were discharged, a ‘generic inpatient’.

If the personas of a person’s patient life-cycle can be traced from prospective patient, to outpatient, to inpatient, to discharged patient to former patient, the hospital knows almost nothing of those experiences, and they know absolutely nothing of the experiences of you as an individual.

The value of what a hospital knows about the experience data it has collected is the hospital’s ability to try to avoid CMS penalties.

The value of what a hospital does not know about the experiences of the patient personas is substantial.

Nine miles into my run I was at the apex of the bridge crossing the bay, leaning over the guardrail to catch my breath. To my surprise, a state policeman pulled alongside of me.

“What are you doing?”  He asked, a tone of concern in his voice.

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 over?” I asked.

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

“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 foot on the guardrail to stretch my hamstring.

“Take your foot off the bridge,” he commanded. “I was about to call for a helicopter. Are you sure you are okay?”

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. “May I continue across?”

“No, you can’t do that here.”

An interesting statement, You can’t do that here. I was looking at a hospital’s website and there was a link suggesting if I clicked it I would be able to schedule an appointment.

I clicked it. The next page told me how good the hospital was. The page after that told me about all of the services they provided. The last page told me that if I wanted to schedule an appointment that I should call the hospital Monday through Friday between eight AM and five PM.

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

Sort of like when I was trying to cross the bridge.

Most hospital websites should offer that disclaimer, You Can’t Do That Here. On most hospital websites people cannot do anything except read about the hospital. People are looking for an easy way to do business with their hospital, a way that has a great user experience.

Maybe you should turn your hospital’s website from a brochure into a business tool.

Does the fact that there are so many different definitions of patient experience among hospitals belie that fact that there is no definition of patient experience? 

Most patient experience definitions seem to be missing a few things; they do not exist much beyond the four walls of the hospital—sort of like EHR, they are highly, if not exclusively, focused on things having to do with HCAHPs.

(If you want a downloadable presentation on the questions not covered by HCAHPS, you can get it at: The Experiences HCAHPS Doesn’t Survey)

Every day many more patients and prospective patients interact with the hospital using the internet and their phones. Much determination on patient satisfaction, by patients, is made using these tools. Retention, referrals, and ‘win-backs’ are influenced here. “Buying” decisions are made and lost here.  The hospital either met or did not meet expectations.

Yet most hospitals invest almost nothing in the two areas that have the highest number of touchpoints.

If I were asked to define a goal for patient experience I would recommends “A remarkable experience for every patient every time, obtainable on any device, at any time, at any facility.”

To move towards the goal of being remarkable, one must talk to patients and observe them in those touchpoints that all patients use. Surveying patients puts out the fire, it does not prevent fires.  Their bad experience has already happened. 

Surveying patients, paying for patient experience data, and paying for coaching does nothing of value for most of the people in the hospital’s radius of influence. It does nothing for all of the prospective patients and nothing for former patients whose next visit to the hospital is never recorded because that patient went somewhere else.

The level of satisfaction for these individuals is determined outside of the hospital’s four walls.  Writing a million dollar check to have a firm coach your employees does nothing.  There are gobs of people—a consulting term of art—who never become patients or never become patients again. These people make their decisions based on their online experiences with the hospital and on how their calls to the hospital are handled.  HCAHP surveys will not entice them to become your patients.

There is not a patient in the country who can tell you the HCAHPS score of any given hospital.

These people whose experiences are unknown belong to a group called the unsurveyable.   They also represent a healthcare spend higher than the hospital’s total revenues for last year.  Why not pay attention to their experience?

My twelve-year-old son commented as I was ready to depart for my run. “Are you really going to wear those shorts?”

“What is wrong with my shorts?” I asked.

“People want to see a lot less leg and a lot more shorts,” he replied.

“How long do my shorts need to be?” I asked. He pointed to a spot between my knees and ankles—capri-length.

If I wore something of that length in red or blue in most major cities in the US I might be mistaken for a gang-banger. Except for the briefcase, the ultra-notebook, and my tan Allen Edmonds wingtips.

That is what got me thinking about forming a management consulting gang, marauding through C-suites wearing white, highly-starched, Egyptian-cotton, below the knee shorts with the Allen Edmonds wingtips—hair gel and manicures are optional.

You probably know that the half-life of something is the time required for a quantity to fall to half of its measured value from what it was at the beginning of the time period.  Its most commonly used with exponential decay, like measuring the age of rocks based on the decay period of radium to lead-206.

The satisfaction with one’s patient experience is the inverse of half-life.  The level of satisfaction of the experience does not diminish over time, it actually grows, and with social media it grows unbounded, at least the bad experiences do—sort of like telling your friend how large the fish was you caught; over time the size of the fish gets bigger.  A story of an unsatisfactory or a bad patient experience has legs, and patients who had a poor experience do their utmost to get their story to the most readers.

A friend of mine who reads this blog called me to relay her story. She is being treated for cancer at a major institution in Baltimore—I’ll leave it to you to figure out which hospital.  She tried to make an appointment to see her doctor because of the side-effects from her anti-nausea medicines.  She said she spent three hours on the phone trying to schedule the appointment.  While she acknowledged that the hospital was the best place for her to be treated she stated that she was going to make it her mission in life to tell people not to go to that hospital simply because they could not handle a simple business process like scheduling an appointment.

Think about the most inane stories someone ever told you.  People, guy people in particular, have a tendency to exaggerate and to add a flourishes that grow over time.  The bad news for healthcare providers is that once patients’ stories hit the web they multiply.

If you want to know how others view your hospital, much more information can be learned from Google than from CMS.  And the opinions on Google, whether accurate or exaggerated have no half-life, that genie is not going back in the bottle.

Hence, the only influence you have over someone’s experience is while they are having the experience.  Once they’ve had it your chance to manage it is over.  And the thing that should concern hospital executives the most is that they do not even know that people are having these bad experiences.

These experiences are not learned from a Ouija-board secret-shopper exercise.

Ninety-percent of the experiences people have regarding their interactions with a hospital are unknown to the hospital, unmeasured by the hospital, and unreported. Companies like Amazon track the successfulness of each interaction of each person.

I watched the movie Jaws recently. It was made in 1975. In 1975 I looked like the keyboard player for the Moody Blues (see photo). I wonder how different the movie Jaws would be if someone tried to make it today using today’s technology.

Bathers would see the shark’s fin. Using Bluetooth, they would triangulate on the fin, send a GPS signal to any CIA drone not targeted on some Middle-East Sadam-wanna-be. The drone would shoot a Hellfire missile into the surf on Amity Island, and the tourists would be dining on sushi.  Game over. Movie over. Pass the wasabi and pickled ginger.

When Jaws was filmed in 1975—where is Richard Nixon when you need him—if any of the visitors to Amity Island fell ill, there was no way for them to go to the Amity Island Hospital’s website to check their symptoms. No way for them to schedule an appointment online. No way for them to request a refill online. No way to seek a second opinion online. No way to call from the beach to talk to a nurse.

Technology is great, unless you have spent the last forty years without it, or you are looking to upgrade to a newer version of your Palm Pilot. In the movie Father of the Bride the wedding planner Franc (Martin Short) responds to Steve Martin saying “Welcome to the 90’s Mr. Banks.”  Sometimes it seems like the business of healthcare, how healthcare is run, has yet to be introduced to the nineties.

Thirty-nine years have passed since Jaws was released. If you happen to be one who studies the business of healthcare it would appear that not much has changed except for the fact that hospital administrators no longer wear bellbottoms, platform shoes, and puka-shell necklaces, and they no longer sport moustaches and long sideburns and long hair.

Accessing a healthcare institution remains the way it was in 1975.  For the most part it cannot be accessed it online. You can barely access it by phone. You still are not a customer or a potential customer.

Many hospitals still believe they have patients, not customers. Unless they change that perception the time will come when they have neither.

There are two ways of looking at access; access to the organization and access to healthcare. 

Healthcare is very impressive. At a recent meeting of the Cardiovascular Leadership Institute Leadership Council of Penn Medicine we watched of video of the transformation of a skin cell into a heart muscle cell—it began to beat!  We can treat numerous cancers and can transplant a face.

We can do everything except schedule an appointment. It may be time to trade in the Palm Pilot.

US soccer fans are a lot like locusts. However, instead of surfacing every seventeen years, we surface every four. Once we are out of the Cup, we are really OUT. Four years ago we will once again try to understand the relevancy of the “offside” rule, and wonder why FIFA does not increase the size of the net and use more than one ball at a time. To badly paraphrase Shakespeare, “We are now in the summer of our discontent,”—the doldrums of professional sports. Pro hoops and hockey, which most people do not equate with sports worth watching have concluded their seven month playoff run, baseball’s 162 games are hitting their midpoint, and football is just a dream on the horizon.

Maybe now American’s can get back to some of the other global sports televised on ESPN channels 31-57, like darts and lumberjacking.

Have you ever wondered why hardware stores sell drills? The next time you are at Home Depot, tell the clerk you need a two-inch hole, and ask the clerk to direct you to the aisle that sells the holes. Stores sell drills because they do not sell holes.
In keeping with the hardware theme, in my workshop I reached for one of my hammers. Have you noticed that hammers survived evolution intact? The one reason hammers haven’t changed is simple—nails have not changed. Long handle, heavy piece of metal at one end. All you need, and nothing you don’t.

The collective noun ‘patient experience’, as viewed by most of the healthcare industry, is no more evolved than a hammer. Thirty-two questions seeking thirty-two answers.
However, patient experience is made up of the individual experiences of thousands of individuals—small things. Small things, which when combined become one very big thing. HCAHPS is the repository by which hospitals have tried to herd the collective experiences of the people in their service area. The problem is that people are no easier to herd than cats.

For HCAHPS answers to be of any use they require the gift of hindsight. It would be better if hindsight was available ahead of time.

Hospitals have a tendency to treat HCAHPS scores like pieces of a large patient experience jigsaw puzzle. Unfortunately, nobody has seen the picture on the front of the puzzle box. Assuming patient experience can be improved just by trying to increase HCAHPS scores makes the solution seem artificially easy, like hoping the nail you are about to hammer isn’t a screw. HCAHPS has a finite number of questions, and a finite number of things to be fixed. But in truth, fixing the problem with patient experience is more like counting votes in Florida.

Problems fall into two boxes; easy and difficult. An easy problem to solve is “Do you want fries with your order.”  A more complex problem, one I faced two weeks ago was helping my daughter buy a dress for the eighth-grade dance. I have some experience buying clothes, and some experience going to dances, and even some experience buying clothes to wear to dances. My eighth-grade dance outfit included bell-bottoms, a puka-shell necklace, platform shoes, and long hair. Ergo, I felt reasonably well-equipped to guide my daughter.  She did not share my confidence, nor did she choose any of the dresses I recommended.

What if most difficult problems were not so difficult? It is easier to get our arms around difficult problems. We know how to acquit ourselves to suss out solutions. We have meetings, someone drafts and agenda, somebody else brings the bagels. We employ subject matter experts—people with PhDs and MDs.  Hire a few consultants. People join the meeting using Facetime, others take notes on their iPads.

That is how we handle difficult problems. That is also how we handle problems that we assume are difficult even if it turns out that the problems are not difficult. For the next three minutes, let us agree to lay aside the oracles of our profession and consider if reducing readmissions and facilitating population health management should be moved from the difficult column to the easy column.

If you choose to continue reading, some of you will conclude that Paul is having a stupidity, and others, hopefully, will conclude that Paul may have had an epiphany.

Washington University in St. Louis reports that twenty percent of patients are readmitted within thirty days of discharge.  Modern Medicine reports that twenty-five percent of patients are readmitted within two years.

Kaiser Health News reported that readmission rates are not budging.  According to AHANews.com, readmission rates for 2012 dropped from an average of 19% from 2006-2011 to 18.4%–perhaps a budge.  Budging or not, it appears that in spite of all of the emphasis and all of the efforts to decrease readmissions, the rate of readmissions remains relatively static.

If the current efforts are not working, what if we tried something else?

Please pay particular attention to the wording of these two Top 5 lists.  The first list seems to lay the blame for readmissions squarely on the patients.  The second list, my list, suggests there is plenty of blame to go around, and could equally be parsed to include hospitals.

I will argue in a second that the ownership of the blame is irrelevant, and that the solution is neither patient-centric nor hospital-centric—it is both. I will also argue that the solution could easily decrease readmissions by double-digits.  But please don’t throw metaphorical tomatoes at your monitor without understanding the entire argument.

The Top 5 reasons for patient readmissions according to the Dartmouth study, Care About Your Care are:

• Patients may not fully understanding what’s wrong with them
• Patients may be confused over which medications to take and when
• Hospitals don’t provide patients or doctors with important information or test results
• Patients do not schedule a follow up appointment with their doctor
• Family members lack proper knowledge to provide adequate care

Written a little differently—my way:

• The hospital does not ensure that patients understood what’s wrong with them
• The hospital does not ensure that the patients understood which medications to take and when
• The hospital does not provide patients or doctors with important information or test results
• The hospital does not ensure that patients scheduled a follow up appointment with their doctor
• The hospital does not ensure that family members had the proper knowledge to provide adequate care

What observations can be made and what conclusions should be drawn from the above information?

According to the Top 5 list patients and their families lack the information that would keep them out of the hospital.  And who has the information that the patients and their families lack?  Say it with me, the hospitals.

So, what do we need to reduce readmissions? The patients need information from the hospitals.  And, here it comes, the hospitals need information from the discharged patients.

Let’s look at two patients, both with very similar issues who were discharged. The first patient goes home with their discharge orders and receives a call from the hospital asking how they are doing.  The second patient goes home and is watched daily, and their health is assessed daily. Which of the two patients is most likely not to be readmitted?

While the answer is obvious, we all know that if a patient is going to be watched and assessed the entire time they are away from the hospital that they may as well remain in the hospital. Unless. What if there was another way to implement that approach?

Let’s begin with the notion that hospitals need a way to ensure that patients and their families have all the information they may need, and that patients ensure that the hospitals have timely (hourly and daily) access to all the information they may need about their condition.

What information is needed by the hospital to lay the foundation for a viable solution?

• The hospital needs access to the right patient information to assess a turn in the patient’s condition.
• The hospital needs to assess the patient’s information early enough to prevent the need for the patient to be readmitted or to go to ED.
• The hospital needs to be able to use that information to know when to contact the patient and to know what to do to prevent the patient’s conditioning from worsening.
• The hospital needs to provide care to the patient that prevents the patient from needing to be readmitted or prevents the patient from going to ED.

What is needed by both the hospital and its patients?

• A timely and accurate way for patients to tell the hospital what the hospital needs to know
• A timely and accurate way for the hospital to tell the patient what the patient needs to know
• A way for both parties to assess the information
• A way of knowing how and when to communicate that either party’s information requires action.

What do they need, when do they need it, and how do we make it happen? Instead of hospitals wishing they had access to real-time information about their discharged patients, and patients wishing they had real-time access to more information about their status, why not make that information available?

What if, prior to discharging a patient, the hospital added the patient to the hospital’s “Discharged Patient Portal?”  The hospital may even provide the patient with a smart-device, with a killer user-interface, to allow the patient to get all of the information the patient needs, AND, to provide the hospital with all of the information the hospitals needs about the patient.

Our cars can do this. They can tell us, based on the data they collect, when we need to see a mechanic. Why can’t we create the same interaction between discharged patients and their hospital?