Airports, heck most public places, are not good places for Myers-Briggs INTJ savants. Passengers rode the airport’s people mover—the horizontal escalator—like it was a ride at Six Flags.  It looked like my security pat-down by a burley TSA agent may wind up being one of the better parts of my day.  I felt a building pressure in my head telling me it may be time for me start thinning the herd.

The thing I like least about flying has to do with my control issues; someone else controls the plane and there is nothing I can do about it especially now that there are armed air marshals on the flights.  The pilot’s voice seemed to say “Put yourself in my hands.”  I find myself drawing caricatures of the people seated around me—I can choose do that, or I can choose to rush the cockpit and wind up being a two-minute feature on CNN with the other passengers asking how I got the gun on board.

USAIR’s SVP of customer experience wrote an article for the in-flight magazine—it was chipper, upbeat, and full of feel-good euphemisms.  Clearly she had never flown on one of the company’s flights.  During the time it took the woman in the aisle across from me to figure out how to work the seat back toggle to store her tray table I had enough time to memorize the article in three languages and translate it into Sanskrit.

The only thing I knew for certain was that my sole mission at the end of the flight was to make it into the aisle with my bag before Tray-Table lady.  This was not a lack of chivalry on my part.  It was simply a matter of trying to keep my head from exploding, for I knew whoever had the misfortune of having to queue behind her would be delayed by several hours.  I vaguely remember asking the chief steward if we could deplane in reverse IQ order.  Skippy, the name engraved on his ID, gave me look that said he and I had a different sense of humor.

Anyway, the woman seems to be resting comfortably.  She has been studiously trying to complete the same Sudoku puzzle for the last three hours.  On my cocktail napkin I quickly sketched out a binary Sudoku puzzle—four squares using only 1’s and 0’s.  I was about to pass it to her, but Skippy headed me off and took the napkin.  Maybe he did not want her to spend the next two hours struggling with it.  Maybe I should have filled in three of the four boxes.  Skippy also mentioned that several of the passengers around me were not enjoying my rendition of Tom Jones’ She’s a Lady, although an elderly woman seemed to be swooning—I must have forgotten I was wearing headphones.

I get as excited about someone sitting next to me as a dog does about a new flee crawling around on his hind quarters.  The woman next to me.  Her outfit looked like it had been knitted from some form of atomic waste.  I was tempted to ask her how she could dress like that but, I worried she would reply ‘From years of practice.’  She looked like a disaster victim might be expected to look.  The only thing missing from the scene was a reporter standing over her asking her how she felt about the plane crash.  As she gnawed angrily at her gum with her front teeth, her fingers gripped the armrests so tightly I could foresee the need to call a flight surgeon upon landing to amputate her arms at her wrists.

When I share about these things some look at me like they are staring at an unlabeled can of food and trying to guess the contents.  Perhaps objectivity is only for the truly unimaginative.

Anyway, that was my flight.  Yours?  Here’s the segue.

Some think of HCAHPs as a stupid thing.  Perhaps we should define the term ‘stupid thing’—doing long division and forgetting to carry the one is ‘a stupid thing’; mixing a red sock with a load of whites is ‘a stupid thing’.  Sometimes differences of opinion can have us all screaming infidelities.

There is nothing stupid about a hospital trying to improve its HCAHPs’ scores.  Now, if a hospital’s only focus on improving patient experience has to do with being fixated on HCAHPs perhaps that may leave the outcome a few fries short of a Happy Meal.

The thing about improving patient experience is that it is not binary Sudoku; an organization ought not to be fooled into thinking that it should only take this approach or that approach.

I just spent an hour online trying to take the perspective of a prospective patient looking at hospitals within a fifty mile radius of my home.  There are fifty hospitals; two in the top 15 in the country depending on how one scores hospitals.  For example, US NEWS & World Report ranks hospitals based on ratings of various specialties and on the cumulative ratings of the specialties.  So, as it turns out, a top fifteen hospital may not even offer the service I am seeking, or it may be the only hospital in my area that does.

Guess what else I learned?  In calculating the rankings there was no mention in the report of the dark side—CMS. No mention at all of HCAHPs.  What does that tell me as a buyer of healthcare?  Absolutely nothing since as a buyer not only do I not know how a given hospital scored, I do not know what the score means in terms of the service I need to buy, as a prospective buyer of a healthcare service I do not even know what HCAHPs means.

Let us assume for a moment that I was a highly educated consumer, someone who had heard of HCAHPs, someone who’s Happy Meal had a full complement of fries. In shopping for healthcare I went to mdeicare.gov and hcahpsonline.org.

Do you remember the children’s tune The bear went over the mountain?  If I recall correctly the reason the bear went over the mountain was to see what he could see.  And do you remember what he could see?  All that he could see was the other side of the mountain.  That was my take away from studying the importance to me as a purchaser of healthcare of the respective dot-gov and dot-org sites.

Some things are classified as nice-to-knows, and some things are classified as must-knows.  People who are involved, as it turns out, are much more impassioned about the nice-to-knows than are those in the must-knows.  There exists somewhere in our great country a sect from within a sect of people, the Ecological Extinction Society (EES) dedicated to preventing the extinction of the one-eyed, yellow-bellied, duck-billed, flying purple people eater (scratch that; one of the voices told me to throw that in), sap sucker.

Is it possible that among us exists an HCAHP EES mentality?  Sort of like the seniors in high school who sat at the cool kids’ lunch table and who were up to date on who liked who and who guarded and secreted that information as though only they had the keys to the kingdom?

Remember the rabbit in Alice in Wonderland?  What we know about the rabbit is that he—I only assume it was a ‘he’ because the rabbit appeared to be dressed like a ‘he’—was late for a very important date.  In the story nobody ever learns the occasion for which the rabbit was late.  The good news is that one could enjoy the story without knowing any more information about the rabbit.  Ultimately, where the rabbit was going had little if any bearing on the story.

If you understand HCAHPs, and know how your hospital scored your knowledge is limited to a small handful of people in your organization.  From the perspective of patients and prospective patients it means no more than where the white rabbit was headed.

On one of my first trips to England I dined—in this case ‘dined’ is a euphemism for ‘ate’—in a large, white, IBM cafeteria on the outskirts of London.  The buffet offered cauliflower, fish, rice, potatoes, pearled onions, bread, turkey—the white meat, and milk.  Various shades of white food.  It was like eating in a black and white film.

No wonder the Commonwealth did not hold together.

The following night I actually did dine.  The restaurant in the English city of Westminster, The Chesil Rectory, was built at a time when people must have been shorter as I had to duck to enter the old building.  The restaurant’s website estimates the building was constructed between 1425-1450.

This was not the IBM cafeteria.  My first clue; even the beer was dark.  The sides included carrots, tomatoes, peas, watercress, and aubergine—eggplant.

At some point instead of trying year after year to marginally improve someone’s experience (various shades of white food), an organization should simply improve it.  While that may sound like a play on words it is not.  Case in point: Microsoft keeps trying to improve customer experience—Windows 2-6, VISTA, Windows 7, and Windows 8 (shades of white food).  Microsoft followed a technology cycle where every year or two people upgraded their PCs.

Apple and Google create and sell customer experience.  Customers line up to buy the new experience.  If you had to guess which of the three firms never actually met with and watched customers use products, and designed the experience around that information, which firm would you pick?

The efforts to improve patient experience in hospitals and customer experience in payers have included dozens of tweaks, expensive tweaks, over years.  From the perspective of patients and customers it seems like a lot of hat and no cowboy.  People do not notice the affect of many slight changes over time.  To your customers, your patients, it is difficult for them to differentiate their experience in August from the one they had two years ago.  Nothing remarkable and nothing memorable.

Current efforts by many organizations remind me of placing a frog in a pot of water and gradually raising the temperature.  The frog does not recognize that the temperature is changing.  From the frog’s perspective all he knows is that he’s wet.

Several organizations have surveyed providers asking them to rank the importance of patient experience and asking them what they are doing to improve it.

Of note: those same several organizations did not survey patients or prospective patients as to what providers could do to improve the experience.  None of the initiatives mentioned by providers in the surveys mentions them asking patients or prospective patients as to what providers could do to improve the experience.

If the IRS announced that their top priority in the next three to five years was an internal effort to improve customer experience, number one, would anyone believe them, and number two, would anyone expect significant change?  If healthcare payers announced that their top priority in the next three to five years was an internal effort to improve customer experience, number one, would anyone believe them, and number two, would anyone expect significant change?

If you are not hearing a patient talk about their experience at your hospital by saying “Wow, that was different” you are just boiling frogs.  Innovate or go home.  If you don’t your patients will.

I received an email from my chiropractor letting me know she had joined a new practice and wanting me to know that “Doctor Jackie is always looking out for me.”

Doctor Jackie, if I had to guess, is about twelve.  She is perky. She always dresses in yoga pants and some kind of Under Armor sweat-wicking shirt.  In short, she looks like she has just led a spin class at the YMCA.

I have another ‘doctor,’ my cardiologist.  He has grey hair along his temples, and spends a great deal of time oversees speaking with other cardiology ‘fellows.’

I see a vast difference between the capabilities of the two, and yet she seems committed to the title.  Perhaps there a little ‘d’ docs and big ‘D’ docs. I have decided to call Jackie a little ‘d’ doc.  When I replied to her email I signed mine “Dr. Knowledge.”  She probably did not get the point but I felt a lot better.

I asked my three children how many sides constitute a box.  They had more difficulty understanding the word constitute than they did telling me that boxes have six sides.  Many of you would probably agree with their answer.

However, none of those six sides gets as much attention as the other two sides; the in-side and the out-side.  Those are the two sides that seem to get the most attention when discussing business.  Apparently, the in-side is the least favorable side because nobody wants to be labeled as being the one person doing all of their thinking on the inside.

Thinking out-side the box used to mean that you were a risk taker, someone who was pushing the boundaries of acceptable thought, someone seeking innovation.  Inside the box people were those who came to work each day and worked on the things they did not finish the day before.  Whereas outside of the box people were those who came to work and worked on things that had to do with tomorrow.

It no longer means any of those things.  Now that everyone thinks of themselves as thinking outside of the box, they are all back together looking at the world from inside of the new box.  The only thing that has changed is the location of the box.

Accordingly, the new 50, as relates to thinking and innovation are those who are willing to color outside of the lines.  This skill has never been thought of as a skill. In fact, as early as kindergarten, people have been trying to correct away that behavior.  They are probably still doing that where you work today.  That does not mean it is a bad thing.  It just means that it makes those around you uncomfortable.

Grab your crayons and follow me.

This morning I cleaned out our spice cabinet. There were a few spices I was inclined to send to the Smithsonian believing that they may have been labeled extinct between the time I purchased them and today.

Thirty years ago, after talking with a GP about my testicular cancer symptoms, I decided where I would purchase treatment. I spoke with oncologists at MD Anderson, Johns Hopkins, and Texas Presbyterian, and I chose TP because they were a mile from my apartment.

Eleven years ago, staring at the ceiling of the ambulance, the ambulance driver decided where I would receive care for my heart attack.  As an aside, to this day that hospital does not know whether I am alive or dead because they never reached out to me after I was discharged.  This hospital was an order taker.  I was dropped off, got great care, and left. 

They had not marketed me directly.  Oh, I am sure there were marketing cluster bombs like billboards and ads on NPR, but those had no affect on me as I had no choice.  Truth be told, they would have had no affect on me had I had a choice.

Yesterday I took my children out to celebrate their first day of school.  Fats food—a Freudian slip—fast food—an oxymoron.  Anyway, at the four-way intersection were a McDonald’s, a Burger King, and a Wendy’s.  Three children.  Three competing interests.  It came down to choosing between a Frosty versus char-broiled—sorry McDonalds.

Drive throughs.  Drive-through fast food.  Drive-through health care.  Going from being an order taker to a provider of choice.  Can an argument be made that in excess of fifty percent of a hospital’s revenues come from taking orders?  I think it can and I think the number is well above fifty percent.

Doctors refer. Payers accept. Patients admit.

What then is the effect of the billboards and NPR ads and Facebook ‘likes’ and telemarketing?

Not much.

The numbers are changing, and the hospital business model is ill-equipped to benefit from the change—there’s a news flash.  By the way, neither is the payer business model.

Fast forward three years from today. People—patients and prospective patients; people—the insured and the prospective insured—are issuing virtual RFPs for both healthcare and insurance.  They are buying.  They are not being sold.

And they are churning; in droves.

The problem is that both providers and payers have a business model that assumes they know how to sell.

There are two takeaways for this missive. 

1. Neither providers nor payers know how to sell.
2. Even if they did, people are not being sold, they are buying.  And providers and payers do not understand the difference.
3. The real bad news is that they are dumping providers (hospitals and insurance companies) faster than they are buying.

For those unfamiliar with “churn” it is a term that will rule your lives for the next decade.  Churn 101: customers drop you and buy services from another firm.

If your annual churn rate is ten percent, and you want to grow your number of customers by five percent, you actually need to grow it by fifteen percent to make your goal.

Now, when was the last time either a payer or provider grew its customer base by fifteen percent in a single year.  Therein lays the problem.

The editor of HealthSystemCIO.com asked me to reply to an article published in the Wall Street Journal.  I would welcome your opinion and comment.

HealthSystemCIO.com:  j.mp/15g169Z

I was reminded of the adage, “What do you call a thousand consultants at the bottom of the ocean?” A good start.  I thought I would start today by being self-deprecating in case it may lead you to thinking of me as being winsome.

What do you call HCAHPs?  A good start?  A start?  Regarding patients and managing their experiences, we are not at the end, we are not at the beginning of the end, nor are we at the end of the beginning—somewhat of a paraphrase of Mr. Churchill.  He also said, “Dogs look up at us, cats look down on us, and pigs look us in the eye…I think I will have a pig.”

We do not know what we do not know.  The funny thing about HCAHPs is almost every hospital would be making the same effort to improve these metrics even if HCAHPs did not exist.  Why?  Because it is simply good business.

The funny thing, the unfortunate thing about applying metrics to business goals is our tendency to hit what we aim for.  In most cases this is lipstick on a leprechaun—achieving the metric has little value other that stating that you hit what you set out to do, because the improvement target was so exiguous as to be inconsequential.

I believe this is the case with how many health systems approach improving their HCAHPs scores.  Let us visit together, your favorite and mine, the hospital, Our Lady of the CMS Anathema.

Thirty-two survey questions.  Thirty-two responses calculated to the hundredth percentile. For the poly-sci majors this may not mean much, but to those of us who labored in the sciences, or anything above mathematics for librarians, there may be something of note. 

For example, let us assume that 1,000 patients completed the survey, and for the question about the cleanliness of bathrooms your hospital scored a 6.28.  the internal HCAHPs improvement committee meets, and they decide that the hospital needs an action plan to raise its clean bathroom score—as best as those patients can recall from seven months ago about whether their bathroom was always clean, usually clean, or if its cleanliness reminded them of the cleanliness of an Amtrak rest room in Manhattan—from a score of—6.28 to a whopping 6.31.  Using our fingers and toes to do the math, don’t forget to carry the one; that difference equates to 30 cleaner bathrooms per one thousand.  A herculean feat? I bet that most patients cannot remember what floor they were bivaqued on seven months ago let alone the cleanliness of their bathroom.

So what do we have? We have an action plan for thirty patients. Add that to the action plan for improving our scores on the other 31 CMS questions and what do we have?  We have an action plan for looking like we are doing something.  We don’t know where we are going but we are making really good time.

Here is my point.  To improve some of the HCAHPs scores requires a mix of art and science—pain management. Hospitals would be working their darndest to improve this metric even if CMS did not exist.

However, and this is my real point, is there a hospital in the US that should be penalized for having unclean bathrooms and too much noise?  Of course not.

No management committee worth its salt—or its salary—should be developing an action plan to have ten percent cleaner bathrooms by the start of 2014.  That is absurd.  Everyone reading this has taken their family on some form of road trip.  You wind up in “Who the heck knows where I am Iowa”, you pull off the highway because you saw a big blue sign indicating that the next exit has Bubba Joe’s Motel, disco, and taxidermy, last rest stop until you reach Singapore.  You have driven thirteen hundred miles since your last stop, your prepubescent son now needs to shave, and you figure “What the heck?”

You pay Anthony Perkins for two rooms—younger readers should Google the movie Psycho, you check out the bathrooms and decide it is safe to shower.  Why is it safe?  On the faux granite counter are ampoules Of Bubba Joe’s Agent Orange skin defoliant, shampoo, and conditioner.  The end of the toilet paper roll has an origami fold, shaped like an architectural model of the Our Lady of the CMS Anathema hospital.  A paper band is wrapped around the lid of the toilet, and the shower plug is in the closed position.

While Bubba Joe’s is not the Ritz, the evidence in the bathroom shows it has been cleaned.  How then if Bubba Joe can clean his bathrooms can a hospital score at the HCAHPs median for clean bathrooms?  If the hospital’s CEO announced over the intercom, “A patient survey indicated that one of our bathrooms was not cleaned. I am coming down in an hour to check it,” you have to believe that all of the bathrooms would be recleaned within the hour. (Apparently recleaned is not a word in Office; it is now.)

This is a freebee.  Clean the bathrooms.  If some Podunk hotel can clean its bathrooms one hundred percent of the time, so can a hospital. Do not set your goals to improve your rating of the cleanliness of bathrooms by 10%. Imagine how the Four Seasons Hotel would react if it noticed that one-third of its bathrooms failed to get a satisfactory rating—that problem would be solved in less than a week.  Set your goal for cleaning all bathrooms every day.

Now, here is the ten-cent freebee.

I am in my bedroom reading. The children are asleep. My wife is watching a reality show on Bravo, Anorexic Albanians making a mirepoix for one thousand refugees in a thimble.  I ask her to turn down the volume because I am reading the complete works of Shakespeare engraved on the side of a single grain of rice.

We get to the point that if she drops the volume of her television show again she will not be able to hear her show and she will not know how to make the mirepoix.  She has done everything she can do to cut the noise to a point where she can still here her show and to where I will not be inconvenienced. If she drops it any more there is no value to her.  Jump back with me now to HCAHPs and the futility of pushing water uphill.  What if there was something I could do that would enable my wife to hear her show and that would allow me to read me book?

What to do.  What to do indeed.  The way hospitals look at the noise problem is to do all they can to make sure that the noise is as small as possible.  Any other marginal improvements would be like squeezing blood from a stone. Ergo. 

Think out of the box.  Most people believe they are already thinking out-of-the-box. You and I both know that while most people claim to be out of the box, their out-of-the-boxness cannot be attributed to thinking, it has much more to do with having followed the lemmings. If everyone is out of the box, all that has happened is that the box has moved.

Change your perspective, if just for a moment.  If your hospital has done everything it can to reduce noise, you have wrapped foam cushions from the Space Shuttle around the salt-free Jell-O you serve at lunch to reduce the extraneous noise, and that has not solved the problem, rethink the solution.

If you cannot reduce the noise your patients hear, maybe you can reduce the noise heard by your patients.

Ten cents. One dime. 

If you have ever flown business or first class to anywhere outside of “God Bless the USA”, you get to your seat, the stewardess or flight attendant—I do not claim to know the PC term for the job—but if you are flying in business class or first class—presents you with a mimosa, and a dopp-kit.  The dopp-kit, which cost them a dime, contains a pair of socks, a sleeper mask, and a pair of earplugs. 

If there was ever a barometer for poor customer experience the airline industry is front and center. “We would like to thank you for flying with us…but we won’t.”  Hospitals. We would like to thank you for having your hip replaced with us…but we don’t.

Once the hospital has done all it can to alleviate the noise, their next step is to think out-of-the-box.  What if the hospital gave patients a way to cut the noise from their end?  Hospitals cannot put noise buffers on the Jell-O.

Why not give patients ear plugs, a sleeper mask, and a pair of socks? Even if it does not solve the entire problem it may lead patients to believe you are trying to help. If you want to be fancy consider a pair of noise cancelling headphones.

I apologize in advance for the length of this piece, but there is a lot that needs to be said.  Grab a sandwich or a coffee, and set aside a few minutes.

“I’ve been working magic here. I could at least get an ‘attaboy.’” Saul Goodman—Breaking Bad

Breaking Bad, Badder, Badest.  Don’t worry about the grammar, this is not freshman English.  Let us assume you have heard all sorts of great feedback about the AMC show Breaking Bad, and so you decide to watch all six seasons of it.  You logon to Netflix, or Amazon, or Hulu and search for the show.  What you discover is that of the six seasons, the only season available to watch is season 4.

Not to be dissuaded you watch season 4.  It leaves you with a feeling like having ordered a steak dinner—or a turkey burger if you are a vegetablist—and the only thing the waiter brings you are the toppings for your baked potato.  Not very satisfying.  Something is missing; a lot of somethings.

If that analogy does not work for you, think about buying a book only to discover that most of the chapters have been deleted.

It is important to have the whole picture, especially if you are basing a business strategy around it.

“If you’re committed enough, you can make any story work. I once told a woman I was Kevin Costner, and it worked because I believed it.” Saul Goodman.

So, I was reading the August issue of HealthLeaders magazine.  The feature story was titled “New Approaches to Patient Experience.”  I could not have refrained from commenting if I had been chained to the floor.  Having already determined that the old approaches were not improving patient experience, I could not wait to read about the new approaches.

“Did you not plan for this contingency? I mean the Starship Enterprise had a self-destruct button.”  Saul.

I read the article.  I read it again, and then I read it a third time.

Perhaps the term ‘new’ is meant to have a certain nuance about it, like when a box of laundry detergent is imprinted in bold letters with the word NEW.

I began looking for the newness and I found plenty of things having to do with communications, hearing, dreams, and culture. I also learned about NPS, the Net Promoter Score, developed by Bain Consulting.  For those who think that if a finding comes from Bain, Booz, or McKinsey, it must be sacrosanct, I have never been one of ‘those’.

NPS shows that the only people (patients) that will likely recommend the hospital are those whose scores are nine or ten on a ten point scale.  Looking back at HCAHPs, almost every hospital has scores in one category or another that are an eight or below.

As an example of why I think it is important for someone to ‘cry wolf” or to yell ‘the sky is falling’, let us look at how the game of golf is scored.  Everyone knows a golfer is given a point for every stroke above par and a point is taken away for every stroke below par.  However, golf is also scored another way using the Modified Stableford System.  This system involves the same players and the same number of shots—it just computes them differently.

NPS does that with patient experience.  It computes the score using the same patients with the same illness undergoing the same procedures.  It even admits to using basically the same questions as HCAHPs—it just computes them differently; it is somewhat akin to counting in Base 12 (think military time) instead of Base 10—whatever the number, it is still the same time in Des Moines.

Please stay with me.  I am still looking for the newness regarding “HealthLeaders’ article…New Approaches to Patient Experience, still searching for innovation—I assume the article meant to include the verb ‘improving’ in its title as every patient has an experience but not all experiences are good. (You too should be.)  Then I come across the bit that discusses how most of the emphasis in the article has to do with inpatient experiences, suggesting or implying that outpatient experiences are somehow or perhaps noticeably different.

Patient experience and satisfaction is listed as a top priority for 63% of hospitals.  Patrick Ryan, Press Ganey’s CEO is quoted as saying “patient experience is ambiguous”.  It is indeed, and improving it becomes more arcane the more nuanced it gets by looking only at the experiences as defined by CMS.

So, here are my talking points.  For the following reasons I can state with a 95% or higher degree of certainty that your hospital, that 19 out of 20 hospitals are not innovating patient experience.

• Plus or minus any given experience initiative, every hospital is doing the same thing.
  • It is all centered around HCAHPs or NPS—measuring a different way does not change the result
  • Hospitals’ efforts to improve patient experience only deal with patients—as opposed to patients and prospective patients
  • It only deals with patient interactions that occur within the hospital facility
  • It mostly deals with inpatients
  • The people who are excluded from all of the costly efforts to improve experience are:
    • Those not surveyed
    • Outpatients
    • Prospective patients
    • These people are a hospital’s potential future revenue stream
    • If every hospital claims they are thinking out-of-the-box regarding patient experience, the only thing that has changed is the location of the box.  For example, if your firm manufactures toothbrushes, and your firm’s idea of a transformative, competitive strategic innovation, one that will gain market share, is to manufacture a purple toothbrush, think again.
    • Hospitals are not focused on prospective patients—a hospital’s future revenue stream
    • Hospitals do not know the experiences of patients or prospective patients for interactions that occur outside of the hospital:
      • On the web
      • On mobile devices
      • When the call the hospital

Continuing to beat a dead horse, does not make it deader.  Get out of the box, way out.  Make it easier for people to do business with your hospital—that is the first step to innovating patient experience.

Study the diagram. What can you be doing to improve the experience of everyone who interfaces with your hospital?

When one considers all of the things that make up a person’s experience with a hospital—I use person instead of patient because prospective patients, people who interact with the hospital online and on the phone have experiences—the impact, positive or negative, of any single HCAHP becomes de minimis.

For example, a hospital buys its data. The survey establishes that the nurse in radiology can be cranky.  The hospital then hires a coach. The nurse learns how to smile.  Problem solved.  What is the ROI on the data buying and coaching hiring?  I do not think there is an ROI, at least not a positive one.

Here is what the voices are telling me.

• ·       Ordinary people (people not employed by the hospital) do not know what HCAHPs are, nor can they define them

• ·       Nobody who does not work at your hospital knows your hospital’s score and they do not know how it compares to the scores of your competitors

• ·       That means people do not use your hospital’s HCAHPs in determining whether to buy healthcare from you—it is a non-factor in their purchase decision.

• ·       These same people do know how difficult it is to schedule an appointment, to understand their bill and to file a claim.

• ·       The hospital does not know the difficulty.  The hospital does not know how that difficult translates into a poor experience and into lost patients.  The hospital does not know because it does not ask and it does not measure.

• ·       Most hospital employees cannot tell you their hospital’s score, how it compared to last year and what is being done to improve the score.

• ·       Employees cannot tell you whether last year’s patient experience initiatives were successful and whether the initiatives raised or lowered the overall score.

• ·       Most hospital financial executives probably do not know what was spent on improving patient experience and what that expenditure cost for each tenth of a point it raised their score. (Some hospitals that spent money to raise their scores actually saw their scores drop.)

If HCAHPs scores are a non-factor for patients and prospective patients—the very people whose experience hospitals are trying to affect, then it is important to ask the question ‘why are we focused only on improving HCAHP-experiences?’  Shouldn’t hospital executives be asking themselves whether paying for a coach to change the temperament of the radiology nurse affected their HCAHP score enough to reduce the penalty?  That is, what did they get for what they spent?

CMS penalizes half the hospitals based on poor HCAHPs, readmissions, and a combination of other factors.  The total penalty will amount to a dollar figure per bed times the number of beds, let’s pick the number $4,000 per bed.  For a 300 bed hospital the penalty in this example is $12,000,000.  A substantial amount no matter who you are.

However, I discovered that the average person who contacts a hospital is worth $7,000 to that hospital that year.  How many people contact your hospital each day?  To keep the math simple, let us assume the answer is 10.  Ten people times 365 days times $7,000 of potential revenue per person is $25,550,000 that could be earned.

The elephant in the room that nobody is asking about is what kind of experience are those ten people having when they contact the hospital?  Was it satisfactory? Did they hire us to provide their healthcare?

The other day we discussed that nobody knows what it costs to acquire a patient.  I confirmed that today with three people, each of whom has a PhD in healthcare economics, and each who help lead the healthcare programs at our country’s leading business schools.

It appears the exact same number of people do not know what it costs to lose a patient.  My take?  It is very expensive.  I am stupefied, especially when we know that McDonald’s can tell you the cost of a single French fry.  A hospital CFO friend of mine told me ‘We know what we charge for everything, but we have no idea what any individual procedure costs.”

Today let’s look at two costs; the cost of losing a patient, those people who choose not to purchase any more services from your health system, and the cost of losing a prospective patient, someone who chooses not to buy any services from your health system.

Some would argue, erroneously, that there are no costs from losing a patient since those people were never our patients, essentially arguing that you cannot lose something you never owned—Word did not like my use of the pair of double negatives.

I also asked the question of these three learned men whether they were aware of any data around the lifetime value of a patient—there is none.  So I did a fair amount of research and cut and pasted and interpreted and came up with a range that I think is pretty defensible.  It appears a case can be made that over twenty-five to thirty years an individual is worth somewhere between $180,000 to $250,000 to a hospital.

Just so neither you nor I need to pull out our Texas Instrument calculators, for this discussion I will use the figure $200,000. 

Retaining one hundred patients in a year is worth twenty million dollars over the next 25-30 years.  (That is only one retained patient every 3.65 days.)  Gaining one hundred new patients in a year is worth twenty million dollars over the next 25-30 years.  Do both in a year and you are looking at forty million dollars in new revenues over the next 25-30 years.  Do both every year and all of a sudden you have good cash flow problems.

Does your hospital have a plan to do either?  Probably not.  A hospital could not erect the number of billboards it would take to generate those numbers.  Taking care of TQE (the Total Quality of a person’s Encounter) seems like a much more cost effective alternative.

The next logical question is what is the relative value of the revenues from a $200,000 patient as compared to the bed-penalty that may be assessed by CMS?  Without boring anyone with the math, the ROI of getting and keeping one patient is grotesquely higher than the per patient CMS penalty.  Given that, why are all the hospitals focused solely on penalty avoidance instead of new revenue streams?

Let me throw in two other thoughts.  First, creating and retaining new customers and avoiding the CMS penalties do not have to be mutually exclusive efforts.  The only reason that they appear to be mutually exclusive is that hospitals are only really focused on avoiding the penalties.  The overarching theory seems to be that lifting the HCAHPs scores, will not only avoid the penalties, but it will have prior patients so in-like with the hospital that the effort of raising HCAHPs will somehow create an equal number of new customers.

Billboards.

Thought number two.  One hundred retained patients and one hundred new patients.  These patients have friends and families, and those people are or will be patients, perhaps even at your hospital.  That means the revenues associated with those retained and new patients are significantly understated.