I overheard two trees talking the other day.  They were trying to determine if when a person falls in a treeless area whether the person makes a sound.

Harvard’s Clayton Christensen built a new line of thought around the notion of getting clients to disrupt their business models.  What do you do with an industry that self-disrupted?  If you multiply it by negative one does it revert to normal?

I was starting a meeting with executives of one of the largest healthcare insurers (think totally disrupted industry—if healthcare insurer is supposed to mean the same thing as payer, is that not by definition an oxymoron) when music entered the room. We looked around hoping to spot the source of the intrusive sound.

“Queen, from the Sheer Heart Attack album,” said one executive. Apparently my phone decided to self-activate at an inopportune time.  Fortunately for me he was a Queen fan.

The purpose of the meeting was to talk about the impact of the Affordable Care Act on healthcare insurers, particularly as it related to customer experience.  He wanted to talk about how to grow revenues.  I told him we should be talking about how not to lose customers.

He wanted to talk about changing phone system vendors for the call centers.  I asked him how many customers they had.  I asked him how many calls a year they received.  I asked him how many customers had to call more than once to get what they wanted.

The answers; three million customers, nine million phone calls, one-third of the calls were repeat calls.  Let’s do some math.  It costs about thirty dollars per call.  Two hundred and seventy million dollars to answer the phone—they could hire Lady Gaga for less than that. Who among us with two hundred and seventy million dollars to spend could not figure out how to solve the problems that were causing most of the nine million calls?

For a tenth of that amount they could build a customer portal that could handle half of the calls on the customer’s time and nickel.  Some problems don’t involve solutions that require innovation or out-of-the-box thinking, they just require common sense. Most customers in any industry call because the firm they are calling did not do something right, because they need something, or because they have a question.  They call because the prior process was ineffective.

Most calls can be grouped by category.  Those that can be grouped are what I like to call Easily Repeatable Processes, ERPs.  Why spend millions of dollars answering the same question thousands of times when you can place the answer to those ERPs on an effective customer portal?  Answer it once and let the customer access the answer at a time of their choosing on their own nickel.

(I was going to suggest that to cut down on the number of calls that payer’s could simply pay their customers’ claims, but that would be hitting below the belt, so I won’t.)

A picture is worth a thousand words.  Here is but one example of how a hospital can rid itself of repeat processes, employee time, mistakes, and waiting by getting patients to schedule appointments and labs the way they would rather do it, online at their convenience.  There are dozens of other processes that could be done this way.

On Friday I had a chance to speak with someone who reads this blog.  He mentioned that my style of writing seemed a little edgy.  I appreciate that he chose such a polite word.

The Science Channel advertised a show regarding an update about how the universe was made.  Maybe it is the cynic in me, but all I could think of was whether someone had sent Morgan Freeman an email dated a gazillion years ago describing a littler bang that preceded the big bang.

It was too cold to go out, too cold to play ball.  So we sat in the house and did nothing at all.

So starts The Cat in the Hat.  So started my day.  For those unable to recall the book, a cat enters the kids’ home…yada, yada, yada…and pretty soon everything in their home is covered with pink stains.  The kids know that their mom will be home soon and that the house must be spotless before she arrives.

I am the Rain-Man of parenting, an idiot savant.  My cat-in-the-hat moment occurred this morning.  Permit me to set the stage.  Last night our fifteen year-old had his friends over for a party.  I was flying solo; my wife was out of town.

The first indication that something was amiss was when I tried to find the kitchen this morning.  From what I was able to recall the kitchen was somewhere beneath the compost pile and Williams-Sonoma warehouse that covered every inch of granite countertop.  The aura was a combination Snapple—Utz—Buffalo Wings.  The entire first floor looked like Animal House’s Delta Tau’s frat house run amuck.

My son was twenty-four hours away from being sent to boarding school in some country not covered on the National Geographic channel.  My message to the boys was simple, little cat Z was about to have a very long day. Mom was one her way home.  You need to be as frightened of her as I am.  I have your phone, I told my son.  You will get it back after you graduate Georgetown Law.

If I’m lucky a month from now I could be managing a Cin-A-Bun in Omaha. No, that is not a quote from the last person who tried to improve patient experience; it was Saul in Breaking Bad.

Improving patient experience.  Improving patient experience scores.  Two entirely different missions.  They involve different teams; different tasks, different scorecards and they have different outcomes.

One scorecard enables you to declare victory if you can spend a few hundred thousand dollars and bump it up by a tenth of a point.  The other measures success in two hundred thousand dollar increments.  A retained patient, a referred patient.

The focus on most hospitals is getting the next tenth of a point.  The focus of most hospitals ignores their largest stakeholder, prospective patients.

Perhaps there is merit in refocusing.

Do you recall that before the recession there were 200 firms in the Fortune 100?

How long ago was that? I think it was around the same time when people still thought you shouldn’t wear white after Labor Day. Time to drop-kick those white pumps to the back of the closet. What made me think of that bit of nonsense was a meeting I had recently with one of the sharpest people I’ve had the pleasure to meet professionally, and a classmate of mine from grad school. She happens to be the founder and president of one of the country’s go-to firms for dealing with business ethics. Having served as a board member for several publicly-traded firms, as well as chairing their audit committees, when the Andersen and Enron scandals hit she went looking for professionals who could help her help her firms. When she couldn’t find the help, she created it.

That conversation got me thinking and made me wonder why there were no longer 200 firms in the Fortune 100. Was it; is it, a matter of business ethics? How often do unethical practices come up when firms interact with their customers? A couple of takeaways from the meeting—for board members to be able to meet their obligation, they ought to do more than reply on the meeting book pulled together by the firm they serve. Simply relying on the book presumes ethical behavior, a presumption not always supported by fact—how much should one believe if the information is being provided by someone who purchased a $900 shower curtain?

What can they do? Due diligence is being reinvented, and the Social Network is leading the charge. One example is to go to the web to see what’s really being said about your organization. Other things I’ve done to obtain facts and opinions, things which particularly gauge how customers and employees feel about the firm include Google Reader, Facebook, Twitter, and YouTube, to name just a few. You don’t need patient focus groups to learn what’s being said, or to learn how good a job your hospital is doing. The patients already have a laser focus. In many instances the group lacking the focus is the healthcare provider.

Firms should focus on maintaining a strong Reputation Bank, one strong enough to be able to handle withdrawals, because you never know when there might be a run on the bank. Might be a good time to look at your firm’s bank deposit slips.  Deposits can be made easily through the social media network.  You can’t stop patients from talking about you but you can shape what they say.

When I was single my mind worked like the minds of most guys.  For example, housework.  Ironing.  I did not own an iron.  My reasoning, that was why God made dry cleaners.  If I ever lost a button on a shirt my head wanted to explode.  My only salvation, as I did not own a needle and thread, was if I had brought home the little sewing kit some upmarket hotels provided along with the coconut-guava soap, I might spend an hour or two during a ballgame trying to sew on the button.

When I married, an iron came with my wife; kind of like the prize that comes in the box of Cracker Jacks.  While I have no problem with a division of responsibilities, I think it makes sense to be efficient when the opportunity presents itself.  As an example, take dusting.  What I discovered is that if your spouse is five feet tall it would be a waste of time for me to dust anything higher than five feet tall.  As a result our coffee table is a tad over five feet tall.  It looks silly but it serves a purpose.

This morning I ironed my shirt.  Scratch one item from my bucket list.

During college, I spent several summers volunteering for a group called Young Life at camps throughout the US.  Silver Cliff was one of their camps in the mountains of Colorado.  Each week we’d take in a few hundred high school kids from throughout the US, and give them the opportunity to do things and challenge themselves in new ways; everything from riding horses to rappelling.

The prior summer I was the head wrangler at one camp—I had never ridden a horse prior to being made head wrangler.  This summer is was the person running the rappelling program.  Needless to say, I had never done rappelled before either.

We received a day’s worth of instruction before we were turned loose on the kids.  One of the first things we had to learn was that the ropes and harness, if properly secured to the carabineers and figure eight, would actually keep you from falling to your death.  My first test was jumping from a platform way up in a tree while on belay.  After a few moments of white-knuckle panic, I stepped over the edge and was belayed safely to the ground.

From there, we scouted a place for the rappel, and found two suitable cliffs, each with about a hundred foot vertical drop.  Watching my first rappel must have reminded others of what it would have been like watching a chimp learn how to use a fork.  After several tentative descents, I was able to make it safely to the bottom in a single jump.

Each day we’d run a few dozen kids through the course, ninety-nine percent of whom had never rappelled, or ever wanted to rappel.  To convince them that it was safe and that they could complete it, I would instruct them in the technique as I hung backwards over the chalk face of the limestone cliff.

Each day we’d have one or two kids who wanted nothing to do with my little course.  Occasionally, while on belay, one of them would freeze half way down the cliff, and I’d have to belay down and rescue them.

Once or twice I’d have an attractive female counselor on belay.  She knew I was the only thing keeping her from being a Rorschach stain on the rocks below.  Scared, and looking for a boost of confidence, “She’d ask, how long have you been doing this?” I’d look at my watch and ask her how many days ago was Sunday.  I viewed it as an opportunity to have a little fun with her.  I also hoped I might even have the chance to go on a heroic rescue.

How long have you been doing this?  That’s seems like a fair question to ask of anyone in a hospital setting.  It’s more easily answered when you are in someone’s office and are facing multiple framed and matted attestations of their skills.  Seen any good patient experience certificates on the walls of the people entrusted with the execution of the patient experience strategy?  Me either.  I have a cardiologist and he has all sorts of paper hanging from his wall.  Helps to convince me he knows his stuff.  Now, if I were to pretend to be a cardiologist—I’ve been thinking of going to night school—I’d expect people would expect to see my bona fides.

Shouldn’t the same logic apply to investing scarce resources to improve patient experience?  Imagine this discussion outside of the hospital cafeteria.

“What do you do?”

“I’m in charge of patient experience.”

“Why?”

“The feds say we’ve got to have it.”

“Oh.  How’s that working?”

“Nobody really knows.”

“How long have you been doing this?”

“How many days ago was Sunday?”

“What’s it cost?”

“Somewhere between this much,” he stretches out his arms, “And this much,” stretching them further.

“Do the doctors want this?”

“Some do, some don’t.”

“How will you know when you’re done if you got it right?”

“Beats me.”

There is a big difference between improving patient experience and improving patient experience scores.

My first trip to London was a while ago.  In fact, I do not think Prince Charles had even started stepping out at night with Mrs. Doubtfire.  It was at a time when television in the UK consisted of BBC1, BBC2, and Channel 3.  Jetlagged, I flipped through the three channels looking for something to watch to help me stay awake.

BBC1 was showing something about the migratory habits of the gnu, televised from some country that nobody in the US had ever heard of—sorry for ending in a preposition—and narrated by one of the dozens of British people who sound like David Attenborough.  BBC2 was playing a game show that had all of the grammarians all-a-tither.  Something to do with contrasting antediluvian prepositions employed by Emily Bronte and Lord Byron.

And Channel 3 was televising a live, week-long dart tournament.  How come ESPN doesn’t hop on that bandwagon?  I opted to watch the darts.  It had the same flare as our Superbowl.  Those attending were kitted-out with face paint, colourful (British spelling) wigs, and dressed like their favorite players, even down to the kilts some were wearing.

I watched the entirety of the first day’s matches and found myself getting somewhat caught up in the drama of the spectacle.  I made sure to leave work spot-on at half-six the next day in order to get home in time to watch Day 2.  By Day 3 I found myself in the hotel pub, drinking Guinness, and shouting at the tele with all of my new mates.

There is a lot to be said for getting what you want from television and videos.  Last night I logged into the Kahn Academy to teach my son about difference quotients for his pre-calc class.  Later that night I used a separate video to help my daughter understand the difference between elements and compounds.

That led me to ask “Where is healthcare’s Kahn Academy?”  Naturally, we will need to pick a different name, but why isn’t there something like this.  Hospitals could even collaborate, seek funding, and build it out under a public service not-for-profit entity.

I think a Healthcare Academy would be a real boost for patient experience.  What if patients could learn in detail about their illness by watching a video?  What is they could learn how to treat and what to do for flu-like symptoms.  Why not have videos that spoke to discharge orders of various procedures? What not have videos showing what to do for and MRI or what happens during an endoscopy?

A lot of the questions patients and prospective patients have could be addressed fully through such a tool, especially in an industry that accounts for twenty percent  of our country’s spend.

What do you think?

Why do you suppose there continues to be so much dissension about healthcare reform, Reform 2.0?

I think it is because Congress failed to acknowledge that ninety-eight percent of healthcare is local; Hyperlocal.  What is hyperlocal?  You know the saying, “All politics are local?”  Well, hyperlocal is local on steroids.  It is moms and dads making choices about who will care for their family.  It’s the doctor down the street, not the doctor chosen by some system.

Individuals on both sides of the aisle, those in favor and those opposed to reform, view healthcare reform and ask “What’s in it for me” and “What will reform do to me?”  The dissension comes from those who have healthcare.  Nobody who does not have healthcare is complaining about reform because no matter what happens they should be better off than they were.

For healthcare reform to work it must meet the test of meCare, it must be viewed as improving my healthcare.  Nobody who has healthcare views reform as meCare.  They view reform as themCare—what’s in it for them.  That is why so many continue to be against reform.  In a zero sum game, somebody with something has to give up something in order for those without something to get something.  The general perception of those with healthcare is that for someone else to be better off they must be made worse off.

What has people talking about trying to kill reform is that nobody who currently has healthcare believes they will see any net gain from reform—they will see a net loss.  If any benefit will accrue to those who presently have healthcare, nobody has articulated the benefit.

To gain support for Reform 2.0, or whatever it comes to be called, those doing the reforming need to dust off their English 101 textbooks and turn to the section on pronouns.  I was a math major, so you may not to take the following at face value, but here it comes.

The most important thing to understand about who supports healthcare reform and to understand why people are in one camp or the other is for the reformers to understand pronouns.

At the end of the movie The Field of Dreams Shoeless Joe Jackson asked Terence Mann to follow him through the cornfield.  Ray Kinsella is upset because Shoeless Joe did not invite him.

Ray Kinsella: I did it all. I listened to the voices, I did what they told me, and not once did I ask what’s in it for me?

Shoeless Joe Jackson: What are you saying Ray?

Ray Kinsella: I’m saying…what’s in it for me?

And therein lays the rub.  That is the question people are asking, governors are asking, and attorneys general are asking.

For reform to work it must incorporate first person interests, not just second or third.  Does that sound selfish?  I do not have a dog in this hunt, and that is probably because I have healthcare.  I do however—and this is going to kill my neo-conservative club membership—think that people who are sick, whether they have green hair and are in this country illegally, have the right, just because they are people—which should be the only criteria for admission—to be treated.

I will pause for a moment as my loyal readers take a few minutes to unsubscribe from my blog.

For reform to work, Congress must learn to conjugate the care verb: First person—iCare, meCare Second and third person—heCare, sheCare, theyCare, youCare. That about covers all the various forms of caring.

What continues to ruffle a lot of feathers is that there is no meCare in heCare, sheCare, or theyCare—hence, the dissension.

The battle over pronouns will continue to show itself as ACOs roll out and as population health gains a foothold.  When it comes to patient experience the only pronoun that matters is meCare, and anything that lessens that will not succeed.

What do you think?

Ninety percent of improving patient experience takes place from the neck up.  The other ten percent comes from CMS.  There are two camps.  The ten percent camp’s members are those that say “we can’t do that”, “that will never work here”, and “CMS already defined everything we need to know about patient experience.”

There is what I call the ninety-ten rule; it is a corollary of the eighty-twenty rule. In the ninety-ten rule ninety percent of the executives work today on what they were working on yesterday.  That leaves ten percent of the executives working on the ninety percent of the issues that can change the industry, the neck-up issues.  Innovation is not about spraying WD-40 on the wheels of the service cart to cut down on the noise.

Case in point—a case study.  Sooner or later there had to be a hospital that gets it.  A hospital that approaches the issue of improving patient experience from the neck up.  As you read through this, see if you can name the hospital.  I warn you in advance that many of you will take umbrage with some of their terminology and with how they present themselves to the market.  My suggestion is that you focus on the approach and the message, not on whether it would play in your hospital’s bureaucracy.

Eighty percent of people looking to purchase healthcare—inpatient and ambulatory—go to a hospital’s website prior to making their purchasing decision.  Fifty percent of people who are scheduled to purchase healthcare from your hospital go to your hospital’s website to decide whether or not they should go to another hospital for service.

In short, they are looking for help deciding where to buy healthcare.  The hospital in this study recognized that and decided to help prospective patients choose them.  They designed a business system—people, processes, and technology—whose goal was to make it easy for people to do business with them.

One of the unifying themes in healthcare is that hospitals do not know what services cost, but they do know what they charge for those services.  Prospective patients do not know either the cost of those services or what they will be charged.

Here is what this hospital did.  The hospital assumed that ninety-nine percent of the people who visited their website were either patients or were people who could become patients.  Based on that they concluded that the information presented on their website should reflect that audience.  They did away with information about their board of directors; they did away with links about making a contribution.  In fact their homepage did away with everything that distracted those ninety-nine percent of their visitors.

In place of those links they created a page that reflected the needs and interests of people who were in the market to purchase healthcare.  They permitted visitors to their website to complete a number of tasks.  For most outpatient procedures and all lab services visitors could:

• Check the price of the procedure or service
• Compare how the hospital’s price compared against other hospitals
• Determine the amount of the service or procedure that would be covered by the individual’s insurance
• Check available appointments
• Schedule the appointment
• Complete the automated preadmissions process
• Read information about the physicians who would be performing the procedure
• Read feedback from other patients
• Read the requirements about what to do prior to coming to the hospital and what to do upon departing the hospital
• Learn how to file a claim with their specific payer
• Interact with the hospital or physician group using online chat

What this hospital learned is that patients and prospective patients have a lot of experiences and have differing degrees of satisfaction from those experiences that have nothing to do with HCAHPs.  These experiences occur when people are shopping for healthcare and they occur after someone leaves the hospital.  These experiences answer questions like:

• Was it easy to do business with this hospital
• Would I come back to this hospital the next time I needed to purchase healthcare
• Would I recommend this hospital to my family and friends

The other benefit is that the marginal cost to the hospital of enabling patients to perform these tasks online was zero.

I try usually not to destroy my credibility until later in the blog, but by now several of you have discovered that the hospital I used in this case study exists only in my mind.

In an era of ACOs and population health in order for a hospital to compete on patient experience—and that is where it will be competing—it is pointless to compete in that arena unless you are prepared to compete on all of the experiences that patients and prospective patients have with your hospital.

Many may wish to argue that this cannot be done or that it should not be done.  For those in that camp I would ask them to present business reasons to support their claim.  For the rest of us maybe its time to approach the problem from the neck up.