The good folks at NPR stated that forty-one states have legislation making it illegal to text while driving—the other nine states are trying to thin the herd.  The commentator mentioned it is almost impossible to enforce those laws.

It is also illegal to skateboard while driving, but this law does not need policing as Darwinism makes it self-enforcing.

Here is how texting and driving ties in with patient experience.  Forty-one states are trying to enforce the law—a hundred million drivers, each moving between twenty-five and seventy miles an hour, a few thousand police officers.  An impossible task.  It is like freeing a hundred cats that were in a box.  How many can you catch?

There is a simple solution to the problem.  Instead of trying to catch each person who is texting why not stop everyone from texting?  Through GPS it is possible to track if the phone is moving.  It must be possible to build an app that turns off the ability to text if the phone is moving.  In other words, do not try to solve the problem one hundred million times, solve it once.

Patient experience.  The present approach to improving patient experience is to solve it a hundred million times.  We ask Sally what she did not like about her hospital stay and then we try to fix it afterwards.  Then we ask Billy.  And Pete.  And Mary Lou Who who was no more than two (Grinch). We only have 999,996 more people to ask and 999,996 additional fixes.

The current approach to improving patient experience has three fatal flaws:

• It is reactive; put out this fire, then put out the next fire.
• You will never run out of fires
• There is no designed global patient experience across the care continuum

The analogy a rising tide lifts all boats does work with the industry’s current approach to increasing patient experience.  For the current approach to work, for patients to feel they had a remarkable experience requires hospitals to implement thousands and thousands of fixes, former patient by former patient.

Why not look for an approach to improving patient experience that only has to be implemented once?  Why not use an approach that creates a remarkable experience for every patient AND every prospective patient every time they access the hospital?

Let’s lift all boats.

• Design a global patient experience across the entirety of the care continuum
• Ensure the design includes:
  • Inpatients
  • Outpatients
  • Prospective patients
  • Ensure the design includes:
    • A digital strategy—the web.
      • Patient portal
      • Customer portal—not the same as a patient portal
      • Social media
• A mobile strategy
• A Call Center/CRM strategy

This is how you get from where you are to a remarkable experience for every person every time on every device.

Please text me your thoughts, but pull over first.

Several years ago I consulted to one of the largest cable television companies—an industry that may be extinct in five years, can you say ‘streaming’—about their marketing strategy. The cable company was excited about their ability to execute marketing campaigns to entice subscribers to subscribe to premium movie packages like HBO and Showtime.

During one meeting they told me about all of the customers who had signed up for a package of HBO and Cinemax for eighteen dollars a month. I asked if they knew whether the campaign had increased their revenues and their chief marketing officer looked at me like I was an idiot—I get that look a lot. 

What we uncovered was that even though thousands of people subscribed to the new package, most of those subscribers were people who had been paying twelve dollars and ninety-five cents each for HBO and Cinemax.  This created a net revenue loss for the company of about eight dollars a month for each person that switched.  This was a classic strategy of “We’re losing money but we’re making it up in volume.”

There is no segue for this piece as none is needed.

The Affordable Care Act.  The next time the government creates a program I am willing to bet it does not give it a title with a built-in oxymoron.  Sadly, the Act has become healthcare’s example of the cable company’s premium movie package.

The stated idea behind the Act was to ensure that more people had access to healthcare.  That was supposed to happen because healthcare would be more affordable—nobody ever promised it would be affordable. The result so far?  Some people who did not have insurance now have insurance.  Many people who had health insurance have lost their insurance.  Others who had it are now being charged more than they can afford and pretty soon they will not have insurance.

If the goal of the Affordable Care Act was to give insurance to people who did not have insurance, they may have minimally succeeded.

If the goal of the Affordable Care Act was to have less people uninsured, has it worked?  Or, has it simply changed the faces of those who are without insurance?  Robbing Peter to pay Paul.

And what about the Care aspect of Affordable Care?  Has Care become more Affordable, or have we become so mired in the insurance aspect of the Act that the intention of making care more affordable has been lost?

If we evaluate the Act honestly, it is not equipped to make care more affordable.  The cost of care has not gone down, it will not stay the same, in fact, it will increase.

It is, and it was from the outset, about insurance.  The Affordable Care Act-has not worked.  The Affordable Insurance Act—has not worked.  The Act was about giving more people access to health insurance.  The mistake the Act’s authors made was assuming payers would be good corporate citizens, was believing payers would act with some degree of benevolence, was believing that payers could be controlled or reigned in.

Cui bono?  Who Benefits?  Three years from now what will we have?  When the dust settles, some without insurance may have it, some with insurance will not have it.  Care will cost more.  Payers will have higher revenues and larger profits.

And what about patients.  Where does this all shake out when it comes to improving their experience?  People who cannot afford healthcare, who cannot afford insurance, will not have an experience that can be measured by HCAHPs or anything else.

This example makes it easy to understand good patient experience, and it makes it even easier to understand what is not good experience.

My daughter and I walked into the office of her orthodontist this morning.  Within five minutes the staff of ten, and the doctor, were serenading a thirty-two-year-old mother of two with a song they had written.  Why?  Because she just had her braces removed.  One the big screen television flashed pictures of the woman, what she looked like before braces and now.  They presented her with gifts, there were balloons, and to eat were many of the foods she had avoided because of her braces.

My daughter checked herself in on some monitor.  She carried with her a cup of wooden nickels that she had earned from her visits over the last eighteen months.  She redeemed the nickels for a fifteen dollar gift certificate; not much a return for a five thousand dollar investment but she was happy.

The orthodontist sends her a birthday card and invites her and a friend to a Halloween party and a spring bowling party.

I’m not sold on the experience for the parents, but the patients are.  And what the heck, we have spent ten thousand dollars, got two fifteen dollar gift certificates, and a slice of pizza at the bowling party.

What makes this experience remarkable and what makes it different from any hospital experience is that this experience was designed, thought through, planned, and executed.

I do not suggest that hospitals sing to the patients or give them wooden nickels.

I do suggest that the entire experience be planned, starting from before they enter the hospital until after they are discharged.

I have been a heart patient for eleven years and during that period I have spent far less than one percent of my time in the hospital.  Yet I have an experience with my hospital even when I am not an inpatient.  And the thing is, nobody has designed any part of my experience.

Yesterday began with the quest for a bunny my dog hid somewhere in the house, and no, we have not yet found it.

Today started with two gerbils having escaped from the cage in my son’s room.  One of the gerbils, the one I know to be the ringleader, actually has noticeable biceps.  Like in a movie of a prison escape, I halfway expected to see a chain of small tissues tied end-to-end, secured off at one end to the running wheel, and the rest of the makeshift rope dangling over the side of the cage—I decided to stop the sentence after having already used four commas.  I have trapped the gerbils in his room and will sort out that problem later.

My more immediate need is figuring out how to remove a bit of malware from my PC.  Google suggested the name of a firm and the software to use.  The link took me to a page with screenshots, sort of a Malware Removal for Dummies approach.  That approach worked only long enough when step one, start the system in safe mode, failed to work.  Fortunately, the site provided a number for me to call, and call I did.

“Oh that is not good,” replied the lad from India.  “If it will not start in Safe Mode, you need a Microsoft Certified technician for which Best Buy will charge you $350.  However…today only…we will provide you with this service for only $250.”

“No, you will not,” I said as I hung up.  I then did what any Neanderthal would do in this situation; I banged on the PC really hard and began hitting a number of keys all at once.  At the moment I am downloading the malware fix for $220 less than my buddy’s suggested approach.

Customer experience.  I had one.  Every customer does.  The rub is being able to know whether the experience was good or bad, and if it was bad what you can do about it.

May I make a suggestion?  Pick you battles and your platforms; have a targeted plan.  Facebook does not constitute a targeted plan.  Some social media expertswould argue that having a Facebook account is a necessity.  It may be necessary, but it is far from meeting the criteria of being both necessary and sufficient.

Last week I read that a certain children’s hospital has more than 700,000 ‘likes’ on Facebook.  Good for them, or not.  To me that is a little like seeing how many Twitter followers you can collect, or how many friends you have on Facebook.  It is about as relevant as you ‘liking’ Justin Bieber or Justin Timberlake—maybe there is something to the name Justin.

That hospital has not had 700,000 patients in its combined history, so having 700,000 is almost irrelevant.  Hospitals in its area also have hundreds of thousands of ‘likes’ and still acquire patients.  It may not have gained them a single extra dollar of revenue.

Is there appoint to having someone holed up in IT, marketing, or business development whose role is to try and perform Social-CRM acts of prestidigitation that in turn yield delighted patients?  Or are all of our efforts simply boosting our feelings of self-worth, sort of a, we don’t know where we are going but we are making really good time, approach to patient experience?

Mindless self-promotion. (I borrowed some of the best phrases here from Gabriel Perna’s May 24th piece in healthcareinformatics.com.)

Here is what I think.  Your hospital cost somewhere between eight and nine figures to build, and salaries and operating expenses run well into the millions.  The lobbies in some hospitals probably cost several million dollars to build.  And why is that?  Because you know it is important to make a good impression. 

Permit me to get way off track for a paragraph.  The above photo of a hospital’s lobby looks more like a Hyatt than a hospital.  That seems to be a trend.  Make the lobby feel customer friendly.  And yet, most hospitals would rather close than acknowledge that patients are also customers.  If people can be both customers and patients, why not have programs that improve both patient experience and customer satisfaction?  They are not the same.  QED.

But guess what?

Every day more people ‘visit’ your hospital on the internet and on the phone than visit the facility.  How much did you spend on making impressions in those venues?  Can patients and non-patients accomplish the same tasks on the phone or by visiting the internet as they could if they went to your hospital?

If they cannot, your hospital has wasted its money. The navigation for most hospital websites appears to visitors like someone took a five hundred piece jigsaw puzzle and dumped all the pieces on your monitor. Most visitors will spend a few seconds looking for the corner pieces and then will give up.

If your hospital has not fully rethought its entire web strategy in the last two years it does not have a web strategy.

If you need a hint for one here’s mine—a remarkable experience for every patient every time that is mobile and available 24 x 7 on any device.

It will cost less than building a new lobby and will have a much higher ROI.

I am rethinking this whole thing about being able to pick your own doctor.  Elvis Presley and Michael Jackson picked their doctors and how well did that work for them?  Now Walmart is going to offer healthcare  Dr Jimmy used to be a greeter, but since he has been with the company for twenty years they promoted him. 

This may be one of those times when I am writing for me to help me understand things.  If you would rather not read it I understand.

My heart attack was eleven years ago next week—the night my daughter turned three.

My cardiologist has told me that I am his poster child for how someone should redirect their life as someone who has heart disease.  In the eleven years I’ve learned enough about heart attacks to write a blog.

Here is where it gets personal.

My dad. 84. Not sure he wants to get to 85.  His three sons and my mom have a different opinion.

The fly in the ointment is that he has had three heart attacks in the last twenty months.  Number four was Tuesday.

If the patient wasn’t my father the remainder of this blog may have had a different tone. If it did I would be wrong because the patient would be somebody else’s father.  The economists would be up in arms talking about the financial burden that he and others of his ilk place on the system.  And they would be right.  But they would not be right if it was your father.

We are one day from Thanksgiving.  I have had fifty-eight Thanksgivings with my dad.  I am praying to have a fifty-eighth Christmas and a fifty-ninth Easter.

So, there he is two days ago.  Heart rate is 160 BPM.  He feels like if he tells my mom how he is feeling he would be putting additional stress on her, so he says nothing.

The accountants in the room are saying ‘good for him.’  His children and his wife are saying ‘Dial 911.’

Everyone who has any interest in healthcare knows that most of the money is spent to prolong someone’s life.  If you are fond of actuarial tables you know this is nonsense. 

If you are the son or daughter, this is money well spent.

Hyperbole is defined as the use of exaggeration as a rhetorical device.  I always thought that was simply how I wrote.

As November slides into December what was hidden becomes visible.  A large wooded area borders our property, an acre filled during the spring and summer with the songs of so many birds that if you sleep with your windows open you had better plan on waking early.  When I look outdoors during the spring and fall I see so many thousands of birds flying north and south that if I was a Monty Python fan I would ponder the migratory pattern of coconuts.

Anyway, the point is that there are a lot of birds, perhaps more than a lot.  So here I am looking at the denuded trees.  I do not see any birds.  I do see one bird nest.  Now this would not bother anyone else, but it bothers me.  One nest.  Thousands of birds singing and flying.  Where do the all of the other birds live?

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 common use is with exponential decay, like measuring the age of rocks based on the decay period of radium to lead-206.

Patient experience is the inverse of half-life.  The experience does not diminish over time, it actually grows, and with the right tools it grows unbounded, at least the bad experiences do.  A story of a bad patient experience has legs, and patients who had that experience do their utmost to get their story to the most readers.

Think about the most inane stories someone ever told you; the size of the fish they caught, what they really said to their boss the day they quit their job.  People, guy people in particular, have a tendency 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.

What this means is that 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.

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 other 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 of each 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 every individual 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.

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

A felt a bead of sweat start to make its way down between my shoulder blades and a slight shiver overtook me. I started to picture her in front of me at a salad bar, inspecting individual chickpeas prior to placing them on her plate.  The only other thing that could have made the situation more untenable is if the grocer decided to play Celine Dion’s Christmas CD over the loud speakers.

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

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

That was my day.

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

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

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

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

Patient experience is measured in percentages; scores like 7.23.  Buy some data.  Hire a coach.  Perhaps this is why patient experience scores only improve or decrease by single percentages.

Where is the hospital’s definition of patient experience?  Where is the plan?  Where is the strategy? What is the retention goal?  The referral goal?

While data and coaching may add a percent or two here and there, to patients and prospective patients the experience your hospital offers will appear the same a year from now as it does today.  Unless you reinvent patient experience, a task that is a lot easier and probably no more costly than taking your HCAHP scores from 7.23 to 8.23.

Four people walk into CMS; two inpatients, one outpatient, and a prospective patient.  One inpatient had a 7.2 HCAHP score, and had his hip replaced at Hospital A and was in the hospital five days. The second inpatient gave birth at Hospital B, had an 8.0 HCAHP score, and was in the hospital for three days.  The outpatient had a colonoscopy.  He did not have an HCAHP score because nobody wanted to know anything about his experience, and the prospective patient was just looking for directions to I-495.

Who had the best experience?  The truth is that nobody knows.

Is it possible that the study of HCAHPs is about as important to patients as the study of ornithology is to birds?

If I were presenting to a hospital team about patient experience as defined by its HCAHPs scores, and I went through the scores one by one, I would expect someone to stop me and say ‘we know all of that.’  “Oh,” I say, “You do?  Then no wonder I can catch up to your knowledge of the scores without having to spend a lot of time studying them.”  The hospital team had invested a lot of time learning about their scores, but that information can be looked up in ten minutes.  Now I am on equal footing when it comes to knowing about their scores, but what do we know about whether those scores mean anything about the experience their patients have?  Is the value in the knowing or in the application?  Knowing the name of something and knowing the something are not the same.

We know that every hospital has patients who leave and who never come back to that hospital, they go somewhere else.  They go elsewhere because they did not have a remarkable experience.  Patients are not supposed to leave and go to another provider.  Leaving means there is a design failure, a design failure with the experience.  And, there is a design failure because the experience was never actually designed, it just sort of evolved.

Which hospital actually believes they create a remarkable experience for every patient every time on every device?  I have learned that if I cannot create something it is because I do not understand it.  Is that why hospitals are unable to create a remarkable patient experience?  Relying solely on HCAHPs will never enable a hospital to create a remarkable experience.  Relying on HCAHPs is like trying to solve a Rubik’s cube while the cube is fighting back.

One can know all of the rules about chess without knowing how to play well.  To me, trying to improve patient experience using only HCAHP scores is like knowing which way the chess pieces move without knowing how to play well.  What we know are the scores, but one patient’s score does not tell us anything about what the patient experienced.  Somebody must ask have we discovered anything about patient experience, or have we only discovered things you can measure in order to discover something about patient experience? 

When I learned that Santa wasn’t real I was actually quite relieved.  For you see I had invented too many different explanations in my mind for how it was possible for him to deliver so many presents to so many children to so many places all in one night.  The number of improbable things that had to happen in order for Santa to be the real solution to how the presents arrived had grown way too complicated.  That same line of thought may apply to thinking that HCAHPs are the solution to understanding patient experience.  Can a patient’s total experience actually be represented by the average of the answers to thirty-two questions? How can a hospital executive test whether their approach to improving patient experience actually improves the experience?  Or is the approach just improving the scores?

The problem with HCAHP scores, with patient experience data, is that one can be so delighted by seeing the data that determining whether the data has real world value takes a back seat.  The data infers that what is being evaluated has precise, measurable answers—the score is 7.23, not 7.22 or 7.24.  The data has precision and certainty.  Individual scores are meaningless if they are used in a way where no conclusions can be made.  Would your organization do anything different if it had received a 7.24 score?  Of course not.

Of all of the possible answers that an individual patient could give to the HCAHPs survey questions, when you look at that patient’s answers, of all of the thousands of scoring combinations that person could have provided, is it not remarkable that that patient would have scored it the exact way they did?  That we cannot predict a patient’s answers means that our experience, our HCAHPs approach is flawed.  If the patient’s answers were predictable one might make a more reasoned argument that the components and mechanics of patient experience were understood.

If you wanted to learn about voodoo, you might expect that the witch doctor knew more about voodoo than anyone else in the village.  However, knowing the most about the problem and having that knowledge result in a solution are different issues.

If you asked individual hospital staff about the confidence they have of their understanding of what makes up patient experience it may range from ninety percent to one percent.  The higher figure would likely come from ‘management’ and the lower figure from people who interact with patients.  That may cause you to raise the question “What is the cause of management’s fantastic faith in how they understand what makes up patient experience?”

It does not matter how remarkable one’s approach is to improving patient experience; if it has not worked it is wrong.  We do not lack the capacity to create a remarkable experience, we lack the imagination.  The difficulty is imagining something you have never seen, something that is different from what has already been tried.

The fact that some people are unable to define the real problem of poor patient experience makes them suspect that there is no real problem beyond what they understand it to be.  The solution lies in being to describe the evidence very carefully without regard to the way you feel it should be. 

The effort to improve patient experience seems to go something like this.  We start with our HCAHP scores.  We do that is because brainwashed us into thinking that every bit of information we need about patient experience can be found in our scores.  We run experiments designed to improve patient experience scores.  We compare the results of the experiments to what we observe.  The scores change—did patient experience change?  If what we observe about patient experience differs from the results of the experiments we ran, the experiments were wrong.  It makes no difference who created the idea or who ran the experiment, if it the outcome does not match reality the experiment was wrong.

Why do we continue along the same path of trying to improve our scores?  I think we do so for the following reason.  If we score in the bottom half of the hospitals it is natural to assume that we need to move to the top half.  Conversely, scoring in the top half is too often taken as a reason to believe that a hospital’s approach to improving patient experience was correct. Their belief in the veracity of their approach is believed in spite of the fact that the results from the surveys vary from patient to patient and month to month.  It is as though their belief in the process today is due to the fact that their prior beliefs were not disproven by their prior HCAHP scores.

What retains patients? If the patient reflects at all he or she will say “I’ve had a bad experience with another provider, but so far I have not had that kind of experience with you.”  These people will stay with you for as long as their remarkable experience continues.

To improve patient experience it does not matter where the ideas come from that are different from yours.  What matters is that they come.  Some people look upon new ideas that are alien to theirs, ideas that seem so outlandish that it seems like they rolled out of bed into a Stephen King novel.

For purposes of this discussion permit me to be Mr. King.  The alien ideas that need to be put in play are the following:

• Patients need to be observed and asked in the context of their experiences
• Many of these experiences occur outside of the hospital
• Experiences are formed on the web, on the phone, and in completing business processes
• These experience matter as much as those measured by HCAHPs
• The only person assessing whether these experiences are remarkable is the patient
• Prospective patients also have many of these experiences
• As long as those experiences are poor those people will never become patients