The temperature showing on the car’s digital display in the garage was thirty-two degrees.  Two minutes after exiting the garage the temperature displayed was zero.  The weatherperson on NPR stated the actual temperature was minus four with a wind-chill of minus seventeen.  NPR also reported that the lowest attainable temperature is somewhere around minus four hundred and sixty degrees, a point at which molecules no longer move—apparently it is the movement of molecules which create heat.

Zero or minus four, I was still some four hundred and fifty-six degrees away from absolute zero, so at least I had that going for me.  The sound made by my car’s contracting metal and glass was that of too-thin ice cracking on a frozen lake.  Regardless of which temperature reading was accurate, the takeaway was that it was cold.

It bugs me when things are named something but the name is either inappropriate or gives the impression of being something it is not.  Snowplow is one of those things.  A plow is something that tills the earth, turns it inside out.  What was on top is now on the bottom and vice-versa.  A snowplow does not do that to snow, it pushes the snow away.  I’m thinking it should be relabeled as a snow bulldozer. 

The car’s thermometer was programmed to display degrees from zero to some upper, unknown limit.  It was not programmed to display negative numbers.  On most days, if I told the person next to me the outside temperature, I would be reporting accurate information.  I would not be guilty of only reporting a generalization of the temperature, something like ‘it’s really cold.’

We do that with how we measure and report patient experience.  We do it with precision, precision gleaned from data we purchase.  We state with certainty that our patient experience is 7.23 on a scale from one to ten.  That is like saying it is fifty-nine degrees on a similar scale.

The number loses value unless one has something with which to compare it.  Yesterday morning it was fifty-nine, and twenty four hours later it was minus four.  Where we live fifty-nine is an anomaly for January, but then again, so is minus four.  But if your measurement tool stops at zero it is fair to say that the tool is flawed.

In the same way that there are temperatures that my car was not measuring, there are patient experiences that HCHAPs is not measuring.  In fact, there are significantly more experiences that are not being measured.

We measure, report, and design our experience improvement efforts on:

• thirty percent of inpatients
• zero percent of inpatient experiences before they enter the hospital and after they leave it
• zero percent of outpatients
• zero percent of prospective patients, visitors, and family members

So, if you are reporting how your organization is doing regarding patient experience, how valid is it to stand before the operating committee or the board and report that your organization scored a 7.23?  The only value of that number comes from where it places your hospital on the continuum of the scores of all of the other hospitals.  It tells you whether your hospital will be penalized.

This is worth restating.  Your score is only a measure of whether your organization will be penalized.  It also helps you understand how far away your hospital is from either getting out of the penalty box or from falling into it.

Your score is not a measure of patient experience.  In order to report patient experience you would have to measure all of the components of patient experience, something hospitals are not doing.  In order to measure someone’s experience you would have to ask them and observe them having those experiences.  What was your experience the last time you called to schedule an appointment?  Were you able to get help about filing a claim by using your iPad?

Patient Experience.  Using the current vernacular of the term, if I looked it up in the dictionary I would expect to see the following:

Patient Experience: (noun), see Snowplow

A remarkable experience for every person every time on every device.

Sometimes the job of being a consultant is eerily similar to the job of being an intelligence analysts.  Being an intelligence analyst assume that there is, that is, intelligence worthy of analysis.

We like to put a bomb in the water to see where the dead fish land.  Unfortunately, sometimes the clients suspect they are one of the fish.

When things go awry in a meeting, especially if I may have caused the angst, I am the one most likely to try to change the morbidity of the meeting by saying, “What if we agree to bring down the tension in the room?  I don’t know about you, but I have a heart condition.  I have fatty deposits in my arteries and I have a stent.”  That usually buys me a second or two and may make them question locking me in an Iron Maiden for a fortnight. 

One of my resolutions this year is to affect a British accent, something from Oxford or Cambridge, somewhat like the person doing the color commentary during a golf tournament.  I do not know if that will allow me to charge more per hour, but at a minimum it may cause people to think twice before they question my grammar.

Some days, deciding which organization gave you the worst experience is difficult.  Today I had two solid candidates by 10 AM—US Air and American Express.  I was booking a flight and was going to pay for it using a new American Express card.  I made the reservation, and authorized the card online.  When I went to pay US Air logged me out and required I re-enter all of the information. I hit ‘pay’ and was told my card was not authorized even though AmEx online stated it was.

I called AmEx, used the automated attendant, and again authorized my card.  Back to US Air, and surprise, I was logged out. Re-entered my flight information–the price I had been quoted was not longer avasilable, re-entered my credit card information, hit ‘pay’ and my card was not authorized.  It reminded me of the directions on a shampoo bottle—although why we need directions on how to use shampoo is beyond me—wash hair, rinse, repeat.

An hour and ten minutes later I actually had made my reservation and paid for the tickets.

So, how are those kind of experiences working for your patients?  When was the last time you called your hospital to ask to schedule an appointment or lab, or wanted to speak with someone about your bill?  How long was your wait?  Did you get the right answer without being transferred or without being given another number to call or without getting a recording telling you to call back during business hours?

Does it work any better if you try to accomplish anything online?  On your laptop, or even worse on a tablet?  Of course it did not.

At best, most hospital websites are online libraries.  They were never designed to be functional, they were designed to be read.  You can read about almost anything the hospital has ever thought you might need to read.  But try to schedule an appointment, pre-admit yourself, order your health records, or look up your discharge information and you are flat out of luck.

Some people actually believe that using EPIC’s or Cerner’s patient portals will make it easy for people to do business with your hospital.  Those people are in for a nasty surprise.

Three years from now the best hospitals will be those whose functionality can be carried around on someone’s iPad.  The rest of them will be like trying to book a flight with US AIR.

People, client-people, expect that if you are going to question their best efforts about something of theirs that you exercise a bit of decorum.  I am that way around the house.  I often tell my family you can tell me what to do, or you can tell me how to do it but you cannot do both.

Take dusting as an example in principle.  I was asked to do the dusting.  The person asking me to dust is five feet one-and-a-quarter inches tall.  I asked myself do I need to dust any furniture whose height exceeds that of the person who will be inspecting my work.  I concluded that no furniture higher than five feet tall needed to be dusted.

Later in the day my wife asked my son what he was doing.  He replied that he was writing his name in the film of dust on the top of her dresser.  Apparently there are times when I need to be told what to do and how to do it.  Apparently it is not sufficient only to do the portion of the task that is being inspected by others.

The current approach to the task of improving patient experience is not unlike the approach I took to dusting.  CMS only measures hospitals against a five-foot tall ruler.  HCAHPs.  Hospitals focus their patient experience improvement efforts on those patient touchpoints that are being measured.  That is how the game is played, for the way CMS defined the rules of the game hospitals will be penalized for failure and will not be rewarded for doing anything more.

What many hospitals have failed to discover is that by doing only what is asked of them they are only hurting themselves.

How are hospitals hurting themselves?  Let me illustrate it with a single business process—Access. 

1. Hospitals are not measuring and addressing the experiences of people who Access the hospital on the web and on the phone.
2. Hospitals do not assess the Access experiences of prospective patients, outpatients, or inpatients.
3. One hundred percent of the people accessing the hospital online and by phone are prospective patients.
4. Patients Access the hospital before they are admitted and after they are discharged, sometimes for months and years after they are discharged.

It is worth imagining how much better everyone’s experiences would be if they could Access the hospital at a time and on a device of their choosing.  A remarkable experience for every person every time on every device.

The story about me and the dusting is fictional, although the idea did cross my mind.

While working in Rio we received a briefing from former members of MI-6 and the Secret Service about how to work and play in South America.  If you were going to be kidnapped, Colombia, they told us, was the best, because the kidnappers treated it as a business and they would do their best to keep you alive.  So for Christmas, I took my family to Colombia.

The woman next to me on the flight to Medellin was watching the movie Proof of Life.  The movie was about a woman living in Colombia whose husband is kidnapped.  Ironic?  I hoped so.  It reminded me of the scene in the movie Airplane when the people on the plane were watching a movie about a plane crash while their plane was about to crash.

I knew little of Colombia other than from a combination of impressions formed from watching the movies Clear and Present Danger and Proof of Life.  The US perception of Colombia was that there were guerrillas hiding behind every banana plant.  Readying myself for a run through the mountains I knew I would have to rely heavily on the fact that I owned a Navy SEAL t-shirt, and that I had seen a television series on SEAL training on the Discovery channel.

I carried with me a bottle of dehydrated water as I made my way up the mountain.  My escape plan, if push came to shove, was to build a hang glider using my shoe laces and by weaving together leaves from one of the tropical plants.

The run proved to be uneventful.  Colombia was amazing, exceeding my expectations.

Nowadays nothing exceeds ones expectations.  A handful of firms meet your expectations, but what firms do not know is that we have lowered our expectations so much that meeting them is still unsatisfactory.

If someone at any organization asked me what my expectations of doing business with them were I would reply that I expect to be disappointed. I feel that way about trying to business with my hospital.

If this is your first time reading my blog, I have been called the Stephen Hawking of Patient Experience,

I have been a heart patient for eleven years.  During that period I have spent a total of four days in the hospital, way less than one percent of the time.  For the other four thousand days I have been having experiences with the hospital; scheduling appointments and labs, checking-in, ordering refills of my prescriptions.

The thing is, none of the ten thousand employees knows about my experiences, or knows if they were good or bad.  The reason nobody knows is because nobody has asked.  And the reason nobody has asked is because the hospital is not required to be aware of my experience, and more importantly, it is not penalized if my experiences are poor.

Patient experience reminds me of the commercial about Las Vegas—What happens outside of the hospital stays outside of the hospital.  Hear no evil, see no evil, speak no evil.

In other words, don’t make waves.  If you were a mariner you would be familiar with the word doldrums.  The doldrums are a period of inactivity; no wind, no waves; the same thing day-in and day-out—Groundhog Day.

It is week 17 in the NFL.  I was listening to a few interviews on ESPN of players whose teams are still in contention for the playoffs.  Every person interviewed said that they were going to treat this last game as though it was a playoff game.  Really?  They play sixteen games.  Now that there is nothing beyond tomorrow they are going to treat their last game as a playoff game.

What if they had approached game one or game six as a playoff game?  Would they still have to treat game sixteen as one?  Had they won any single game that they lost maybe the outcome would have been different.  In September players say they are playing to compete in January when everything is on the line.  Perhaps they should notice that if they do not play like everything is on the line in September they will not have to worry about January.

We do that in healthcare. We treat patient experience that way.  We wait to learn the results of the next round of surveys, then we make a plan, then we try to implement the plan.  Civil wars were won and lost in less time.  It is like reading yesterday’s paper to learn yesterday’s news.

It’s time we make a few waves—if you do not nobody else will.

I wrote and posted this in December of 2009.  Rereading it this morning it made me wonder how far we have come. What do you think?

‘Twas the night before Reform when all in the House

Were Tweeting and blogging and squawking like grouse.

Their bill filled with zeroes and commas and flair

In hopes that the Senate would soon be there.

The voters were restless, and in need of good care,

And they whined and they pleaded and they yelled ‘don’t you dare.’

“Don’t sidestep this issue, don’t do it for votes”

“Don’t kowtow to payers or we’ll be at your throats.”

With Pelosi and her Botox and while Reid took his nap

Didn’t care if the people put up with their (you rhyme it, I’m pretending to be neutral).

The docs sat on the sidelines, bemoaning their fate,

While payers dressed like succubi caroled “ain’t this great?”

On the lawn of the White House there arose such disdain,

As the public fought reform from ‘Frisco to Maine.

MSNBC, neigh now Comcast, buttressed their base,

And Fox, aka Rupert, said it was all a disgrace.

The words on the pages of the newly printed bill,

Hid nuance, erudition, obfuscation, and skill.

Do not read the details, adjectives and signs,

Do not worry how it impacts your bottom line.

We are here to pretend we did that of import,

To Hell with Medicare, Medicaid and the sort.

It’s voters we want, It’s our doxology, our mantra,

And this year silly people, this year WE are Santa.

On Boxer, on Biden on Fienstein they came,

And we chortled, berated, and chided by name.

“What about seniors, and sick people” we cried.

“What about uninsured, don’t you care if they died?”

“This is about people you meet on the street,

People who must choose between their meds and to eat.

It’s about Lipitor, Xanax, Prozac and Viagra,

It’s about doing what’s right, do what’s right or we’ll bag ‘ya.”

And then in a twinkling I heard in my head,

The gnawing and chiding of Congress, who said,

We cavorted and sucked up, the best we knew how,

We spent bucks, made payoffs, and said the time is now.

Festooned all in new regs from NHS to VA,

There were those who suggested, this is not going to play,

HITECH and ARRA are not making it fun,

RHIOs and RECs will soon come undone.

We’re paying the hospitals to do EHR,

We know it seems silly, like we lowered the bar.

If that doesn’t work we will tax them instead,

Make them spend gobs of money, make their budgets bleed red.

Spend it, refund it, and print new money now,

Buying Canada would be cheaper and easier but wow.

They want to sign something, sign it soon, sign it fast,

But don’t assume that they’ve read it from first page to last.

We could’a been more like France, like the Swiss or the British

Make us more European, make our rich people skittish.

The tall socialist exclaimed as the dems shifted right,

Will Obamacare fail, have I lost all my might?

With the penchant Americans have for all things European I have been wondering if there is a way to make a go of a business that combines Monster Truck events with Pamplona’s running of the bulls.  Could I make money building a business that brought the running of the bulls to cities throughout the US indoors?  I bet you could pour a few hundred truckloads of dirt on the floor of Texas Stadium, get a lot of people to pay for the privilege of trying to outrun the bulls, and fill the seventy-thousand seats at a hundred dollars a seat.  Perhaps we could combine it with “La Tomatina,” the annual tomato fight in Bunol, Spain where 100 tons of overripe tomatoes are thrown in the world’s largest food fight–those Spaniards sure have a knack for having a good time.  We could sell bags of rotten tomatoes at the concession stands.  Maybe the new Fox Sports Network would carry it live.

I spent the last several days in Tampa. I’ve been coming to Tampa since my parents retired there twenty-six years ago.  There has been highway construction each time I’ve been there.  They are still building roads in Tampa, and the construction takes traffic to a standstill. The good news is that you can get to anywhere you need to be in Tampa in ten minutes as long as you are driving a Klingon Battle Cruiser.

Some projects, like Tampa’s road construction, are not designed to end, they just go on and on, and people become so accustomed to the effort that sooner or later they no longer notice it.

Improving patient experience via HCAHPs is one such project.  How many years has your hospital been working at it?  What year is it planned to end?  Apparently there is no statute of limitations.

What is the net value of your investment?  Has there been or will there be return on the investment?  Will you be able to look back a few years from now a say with some degree of certainty that your efforts improved patient experience?  Do the efforts year in and year out seem to be focused on fixing what was already supposed to be fixed?

Best case with HCAHPs, maybe you will be able to look back and say that all you really achieved was avoiding the penalty.

In Tampa when they finish building a road, they move the equipment and the builders to another area and build a different road.  They do not build a road, tear it down, and then build the same road again and again.  That would be silly.

In the event of a water landing your life-vest contains a location light that will illuminate when we slam into the hard as concrete water from thirty-six thousand feet, making it easier for the Coastguard to locate your body.  There was no warning about carrying C4 or RDX in your undergarments or wearing a pair of clogs constructed from match-heads.  I did not know if that was because airlines thought nobody would ever again attempt such a foolhardy method of bringing down a plane, or if they had simply given up on being able to discover the culprit before it was too late.

It is illegal for you to tamper with or destroy the smoke detector in the plane’s lavatory.

Really? They have to issue that warning because on some flight not only must someone have tried to destroy the smoke detector, but because there was no warning about the illegality of it someone was able to use not knowing as their defense.  This is the same reason there is a warning on your toaster telling you not to make toast while you are taking a bath.

There are on hundred and twenty-six seats on this plane.  Therefore the probability of the one screaming child sitting directly behind me was slim.  I was never very good calculating probabilities.

According to the English, the play, Waiting for Godot, is the most significant work of the 20^th century. It is an absurdist play in which two characters wait endlessly for someone named Godot.  Maybe it is like a hundred and twenty-six people waiting for the plane to crash-land in water—I think the term ‘land’ is a bit superfluous. 

I read what Wikipedia contained about the play.  Apparently there are almost as many interpretations of what Samuel Beckett meant by writing it as there are people who read it—everyone has an opinion of everything.  Depending on the person one would think Beckett intended readers to think the play had to do with one of the following; The Cold War, Freud, Jung, Existentialism, Ethics, Christianity, an autobiography, and homoerotica.  I did not know Beckett had such range.

I am always amazed when people interpret what people write, when they try to ascertain the true meaning of what the author, someone with whom they have never spoken, had in mind.  We have built an entire field of study, English Literature, around these empty suppositions.  People with PhDs ask students—students who wonder why they did not study something else—what so-and-so intended when they wrote such-and-such.  Not only do they ask the question, they believe the answer is important.  They will grade the poor student to see if the student was able to spit back the truth as they imparted it.

Here’s a secret about authors and about what they do and why they do it.  They write to tell a story.  That is it.  I write. There is no hidden meaning.  When there are no more words to write, hopefully the story has reached the end.  My son’s teacher asked him why the author of a poem used a certain phrase in a poem.  I told him to tell the teacher the author used it because it rhymed.

If Beckett had wanted people to know what he thought about The Cold War he would have written about it—by the way, for those who thought he was writing about the “Cold War” the phrase barely existed when he wrote Godot.  If he had written an autobiography, he probably would have titled it “Waiting for Godot: an Autobiography.”

Too many of us spend way too much time trying to discover what was really meant by an author or a speaker.  We try to interpret a report.  We read between the lines to find the hidden meaning.  We do that with the patient experience data we purchase.

We have probably learned less from our data than we think, and we spent a lot of money trying to learn more, trying to figure out what else it could be telling us.  Personally, I think all of the things about patient experience that are not being looked at can tell you a lot more than the things that are being studied.

If for example the entire patient experience across the care continuum contained one hundred touchpoints, and hospitals only had data on thirty-two of the touchpoints—HCAHP scores, what could having data on the other seventy-two touchpoints tell us?  What if hospitals knew the experiences of people who were scheduling and appointment, who were being admitted, who wanted a second opinion, who didn’t understand their bill?

Sometimes it is easier to get more data, different data, than it is to squeeze more information you’re your old data.

I am fascinated by the use of robots in healthcare, from steerable micro-robots that travel through veins to precision robots guiding surgeons to the delivery of meals to patients in the hospital.

What makes them so useful is their accuracy.  If they get it right the first time they will get it right the millionth time.  They do not get bored, they do not have an attitude, and they do not need a supervisor.

A robot performs its functions using the computer program that tells it what to do.  Without the program the robot is nothing more than a door-stop.  It is the program that enables the robot to replace or supplement the work that would be done by a person.

I am more fascinated by where robots are not used in hospitals.  If robot technology—think computer programs—can be designed and used to do something as complex as treating someone, as saving someone’s life—the ultimate patient experience benefit, why can’t it be used in other areas like improving other aspects of patient experience and acquiring new patients?

Remember, what makes the robot work, what gives it its value is the program.  So, how do these programs enhance patient experience? Can computer programs possibly provide a remarkable experience for every person every time on every device? Yes, and here is how.

Two ways people access the hospital; on the internet and by phone.

Two groups of people access the hospital; patients and prospective patients—everyone else.

Two experiences people have when they access the hospital; remarkable and unremarkable.

Specifically I am referring to a customer portal—not the same thing as a patient portal, and a call center.  People contact the hospital because they are seeking something, an answer or information, or because they have a complaint they want resolved.  Well-designed user experience programs can provide accurate, high quality responses with a high degree of precision:

• Time after time
• Twenty four hours a day
• Faster
• With zero marginal cost
• Zero rework
• Zero duplication of effort

Call Center:

The call center program is Customer Relationship Management (CRM).  Less than twenty percent of hospitals have a CRM product.  Of those who have it almost none of them use it to manage customer calls; they use it as a sales tool.  The program’s purpose is to enable the people who answer the phones to provide the best answer, the right answer to each call.  The CRM is designed to satisfy the person who calls, and to give them enough of what they want so that the person does not have to call a second time.  It shortens the length of the call, enabling the hospital employees to take more calls.

Customer Portal:

People access the hospital because they want to buy healthcare, or are buying it, or because they have to do business with the hospital.  The rest of the world calls people who want to do business with an organization customers.

For too long hospitals have relied on Information Technology and Marketing to decide what customer experience means to the organization. The vast majority of hospitals do not have a working definition of patient experience. I have not found a hospital that has formally designed patient experience across the continuum of care.  The customer portal is for patients and prospective patients and it should be user-centered and designed by patients.  A customer portal is not for getting information about the gift shop or the board of directors.

The purpose of a hospital’s customer portal is to make it easier for people to do business with the hospital and to decide to buy services from the hospital.  Anything else is just noise.  And the people who know what they need from the hospital are the patients and prospective patients.

What can a customer portal do?

With the right design a customer portal can:

• Perform in-whole or in-part:
  • Preadmissions
  • Admissions
  • Scheduling
  • Discharge instructions, monitoring and compliance
  • Billing
  • Collections
  • Reduce the cost of back-office personnel
  • Increase the accuracy of each person’s touchpoint
  • Greatly reduce errors and rework

I call it iHospital or myHospital.  Everything nonclinical I need from my hospital on my laptop, my tablet and my phone, all in one place and whenever I want it.

The worst thing for your hospital is for it to be the third or fourth one in your market to build it.

To those who would argue that because not all of our patients want to use computers, and for this reason we should not do what you described, I would ask you at what point does it become worthwhile?   Twenty-five percent of your patients, fifty, ninety?  Every patient and prospective patient who goes to your hospital’s website is already looking for a technical solution to give them some or all of what they need.

In another life I could have been Batman, but most days I settle for just being the designated human.

Under the Freedom of Information Act journalists from the Durdge Report discovered an email from the CEO of one of America’s largest health insurance companies to its employees regarding a change in their strategic direction in an attempt to reap benefits from the implementation of the Affordable Care Act.

It read in part:

“The other night my family and I were watching Warren Beatty’s movie, Heaven Can Wait in which Beatty, a former NFL quarterback, is reincarnated as a wealthy CEO, but one with a totally different personality.  During the movie he is meeting with his board and listening to his customers complaining that the firm’s canned tuna subsidiary is killing a lot of porpoises in their fishing nets.  Beatty replies to his board ‘Wouldn’t you pay more to save a fish that thinks?  Let the other firms build plants in the wrong places, let the other quarterback throw a gurgle.  Let’s be the team that makes the rules, that plays fair. It will cost us millions but we don’t care because we’ll come out ahead in the end.’

In my report to our board of directors I noted that there is an entire group of stakeholders that are not being served.  It is not the group everyone is talking about and fighting over, the uninsured, it is the insured.  It occurred to me that our greatest opportunity to grow our business has been right in front of our eyes the whole time.

Annually we spend millions of dollars employing thousands of people to adjudicate claims.  Adjudicate is a polite word for deny.  We have dozens of attorneys working around-the-clock drafting policy loopholes that allow us not to pay our customers’ claims.  We are very, very good at what we do.  But nobody likes us.

Accordingly, I have instructed our marketing department to design a new campaign around our new strategy.  We are going to be the company that plays fair.  We are going to let the other insurance companies kill the porpoises.

We are going to be the company that pays our customers’ claims.  It will cost customers more, but they will actually get what they pay for.  It will cost us millions but we don’t care because we’ll come out ahead in the end.”

When you live in a house of mirrors or fall through the looking glass, the impossible becomes possible.  On my best days I try to solve three or four impossible things before breakfast.  This problem, even when viewed from the land of fantasy does not appear to have a solution.

According to Princeton Survey Research forty-percent of us would rather pay the fine than pay for insurance.  I bet that throws a wrench in Sebelius’ spread sheet.

Oh, and given that only twenty-eight percent of us were uninsured before the Act, the wrench must be huge.  This is sort of like the business strategy that states “We’re losing money but we’re making it up in volume.”

So, potentially when the dust settles there will be more people without insurance than there were before we made insurance affordable.

This means that the price of insurance for the remaining sixty percent will increase.  Therefore, some of those people will drop their coverage and elect to pay the fine.  In business terms this is known as a death spiral.

At this rate by June nobody will be paying for insurance because nobody will be able to afford it.  The insurance companies will be out of business.

If that was the final outcome, I might argue that that is not a bad thing.

But that cannot be the final outcome.  Somebody will step in to provide insurance—just like they do in Europe, only our somebody will have a Washington DC zip code.  I think that was the plan all along, but I am a ‘glass is half full’ kind of guy.

BTW, how’s your French?