Rants & Musings

Patient Experience: Is it worse than your cable company?

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Several of you wrote to inquire about a term I used, churn.  Customers churn, and patients churn.  Churn is the opposite of retention.  Instead of retaining patients, they churn, they go somewhere else.  It’s like multiplying retention by negative one.

I am curious to learn if any of us consistently has good customer experiences with the professional services firms we use.  I bet we do not.  We have satisfactory experiences; we have portions of our experience that are somewhat satisfying, perhaps even bordering on good.  Because our experiences in general have degraded over time, what would have been viewed as a poor experience a few years ago now hides behind the veneer of acceptability.  Our standards of what is acceptable have declined right along with the professional services we consume.

Professional services firms include accounting, law, cable, phone, healthcare, and there are many others.  One characteristic about buying professional services has everything to do with the service; that is why ‘service’ is in the name.

A while ago I spent two days in Nashville at the Loews. Great hotel. The clerk in their lost and found gave me a power cord for my phone. The attendant in the exercise room thanked me for allowing him to serve me during my workout. Sort of makes me feel like I should return the towels—just kidding.  At the end, they asked me, “How did we do?” They didn’t ask about my room, or the food—they knew those things were perfect. They asked about how the people performed. Competing on service.

Last week I rented a car from National.  I always rent from Enterprise.  Enterprise has no perks, no frequent renter upgrades.  I get a car, the same car I could have received from any other rental company.  National gave me a car. I was the only person in line and it took twenty minutes.  I had to initial eighteen times.  National’s car was fine; same as what I would have rented from Enterprise. 

I will not rent from National again.  Why?  They did not ask me how did we do, and how they did was poorly.  Enterprise knows their car will be perfect; they do not need to ask is everything with the car was okay.  Enterprise always asks how they did.  They do not need to ask because their service is always perfect, but they do ask.  They asked how the people performed.  They compete on service, not on cars.  The cars are the commodity.

Most professional services firms know you are no longer a customer because you cancel their service.  Actually, the firm does not know.  It is a closely held secret among you, the person with whom you spoke, the recording of your call—for quality and training purposes–, and the 1’s and 0’s in the computer storing your customer record.

Healthcare is unique in that hospitals never know you are no longer their customers.  Suppose two years ago you, or a family member, had their gall bladder removed at Our Lady of Perpetual Satisfaction.  Or, suppose last week you took your son in for x-rays for an injury sustained playing baseball, and the x-ray showed that surgery was needed to repair the bone.

The hospital has no way of knowing two very important things.  One, they do not know that you had you appendix removed six months ago at another hospital or that your son had his surgery somewhere else.  Two, they do not know why you chose not to return to them for care.

Look at your call center for example.  It probably closes around 6:30.  Not even Comcast closes at 6:30.  This means from a customer experience standpoint your hospital’s customer experience is already worse than that of your cable company.  By the way, that is not a good thing.

For the most part, minus chronic care, every patient is a new patient even though the patient may have been there several times before.  Each time the patient visits a hospital they have a choice about which hospital they will visit.  Unlike cellular companies, hospitals cannot lock in patients for a two-year term.

If hospitals do not know that you left, they will not make any effort to get you to come back.  Since they do not know why you left, they have no way of knowing what they could have done differently that would have caused you to stay.

That makes for a pretty tough business model.

The funny thing about being in a services business is that there are always plenty of people selling the same service.  I can probably get me hip replaced or my knee scoped at a dozen hospitals within ten miles of my home.  I believe that no matter which of these twelve hospitals I choose, my hip or my knee will be better when I leave.

I also believe that by definition the service I receive can only be the best at one of those hospitals.

Who among us is competing on service?

Just to throw a metaphorical tomato at the screen, buying patient experience data, or being able to recite your HCAP scores does not enable you to compete on service.

Why not Improve Satisfaction Instead of Measuring it?

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­One of the uncomfortable things about flying is how close you are to the other passengers.  On my return flight from Florida I could see from his teeth that the passenger in the window seat must have had spinach for lunch.  The most troubling part of my observation was that the passenger was in another plane, and neither of our planes was on the ground.

To back track for a second, I observed something else on my drive to the airport.  We are all familiar with the painted white lines that divide the road lanes.  On some roads, raised reflectors have been inserted into the road’s surface in addition to the painted lines.  At night these road nibs reflect your car’s headlights helping you to stay in your lane.

What’s your point?  If asked the color of these nibs we would response that they are white, just like the white strips.  Those who answered white would be half right.  As I looked in my rearview mirror I caught a glimpse of the backside of the nibs, and for some reason I was surprised to see that unlike the front, the backs of the reflectors were red.  It occurred to me that the reason they are red is to warn you that if you see red you are going the wrong way.

It goes to show you that just when you think you have the answer it may be time to look in your rearview mirror; you may be going the wrong way.

That may be where some, if not most, hospitals are with regard to patient satisfaction.  But, don’t feel you have to take it from me.  According to Amednews.com, “The study by Rozenblum and his colleagues said there seems to be more emphasis among health care organizations on measuring patient satisfaction rather than on improving the patient experience.” March 13, 2013.

This bears repeating…there seems to be more of an emphasis among health care organization on measuring patient satisfaction rather than on improving the patient experience.

Stack all the reports your organization has purchased concerning patient experience data.  Those reports show your hospital’s scores, how your hospital compares to other hospitals, means, averages, standard deviations, and the square root of the hypotenuse.  Now, next to the stack of reports, stack all of the money your hospital has saved by implementing what it has learned from the reports.

I’m sorry, can you speak up?  Oh, you said you have not saved any money.  Well, let’s try another tactic.  Let’s have dinner for every patient that the experience data helped the hospital retain plus all of the new patients referred based on the things learned from the patient experience data.

J’ai mangé seul.  That is French for ‘I ate alone’.

9% of Hospitals Have a Patient Satisfaction Plan

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The phone rang last fall. It was the school nurse asking me if I would pick up my seven year-old son. When I inquired as to the reason she informed me he delivered an organ recital—a long-winded recitation of ones ailments—the classic symptoms of the crud; tummy-ache, non-responsive, crying. She’s the nurse, so without better information, who was I to question her diagnosis?

We got into the car and his tears started flowing. “Do you feel like you’re going to be sick?” I asked as I looked at the leather upholstery. He didn’t answer me other than to whimper. He didn’t seem sick at breakfast. I remembered that he was crying last night, but his tears had nothing to do with his stomach. While he was crying he was hugging his favorite dog, our five year-old Bichon.

We had just learned that the Bichon was very ill and will never be a six year-old Bichon. The person having the most difficulty with the news is my youngest. I asked him if that was why he was crying in class and he confirmed it was. Dads know everything, at least some times.

So, here’s the deal. The school nurse had done all the right things to diagnose my son’s problem, but she stopped short of determining what was wrong. Let’s try a more relevant situation from the perspective of patients and what they think of their interaction with the hospital. 

A survey of 1,004 physicians and nurses in four countries found that 90.4% said improving satisfaction of patients during hospitalization was achievable. But only 9.2% said their department had a structured plan to boost patient satisfaction, March BMJ Quality and Safety.

What does the hospital know about what their patients think about them?  Has anyone ever asked of a patient, “What do you expect from us throughout your experience?”

At minimum patients expect that when they call the hospital they will receive a correct answer to any question they ask one hundred percent of the time.  At minimum patients expect that when they go to the hospital’s website they will find what they need or accomplish a given task one hundred percent of the time.

Does that happen?

Didn’t think so.  Planning to meet expectations without knowing what they are is a lot like playing on the tail on the donkey; blindfolded, spun around, and set off to hit the target.  Failing to plan for patient satisfaction is planning to fail at satisfying patients.

Hospitals are spending a lot of money and losing a lot of patients by trying to diagnose their patient satisfaction problems.  The problem is they quit diagnosing the problem before they find the answer.  To make matters worse, very few hospitals are even looking in the right place.

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The Stilleto Theory of Improving Patient Satisfaction

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“I just returned from the Prada show in Milan”—that was the opening line from a piece on NPR. Apparently this year’s runaway hit on the runways has to do with high heels, with the emphasis on the notion of high.

The following comes from the UK Telegraph: The girls looked like rabbits trapped in the headlights; their faces taut and unsmiling, their eyes wide with fear and apprehension. Were they about to undertake a parachute jump? Abseil down a 1,000 ft mountain? None of the above. All they were doing was trying to negotiate the catwalk at Prada during this week’s Milan fashion shows in shoes that were virtually impossible to walk in. At least two models tripped and fell on to the concrete floor; others wobbled and stumbled, teetering and tottering, clearly in agony, and all the while their minds were fixated on just one thing: reaching the sanctuary and safety of the backstage area without suffering a similar fate.

According to the NPR reporter, the heels are so high that regular people—women people that is—can’t seem to walk in them without falling. This problem has led to the creation of an entirely new micro-industry. In L.A. and New York, there are classes to teach ladies how to walk in very high heels without hurting themselves. These classes are being offered through dance schools that couldn’t fill their dance classes—they are now booked solid.

Tell me this isn’t the same as trying to walk and chew gum at the same time. Multitasking.

Now before I make fun of some thirty year-old who has to relearn how to walk, let us turn our attention back to those dancing—cum—walking schools. What makes this story interesting is that those dancing schools saw a need and re-engineered a part of their business to meet that need, sort of like we’ve been discussing regarding the need to improve patient satisfaction in your hospital.  With everything going on in healthcare, many things will change.  If they don’t require change, you probably have not been paying close enough attention. 

What’s important are having a plan to define what needs to change and managing the change.  Assess business processes, remove outdated duplicated processes.

Now I’m going to go saw the heels off my wife’s shoes before she hurts herself.

 

The Stilleto Theory of Improving Patient Satisfaction

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“I just returned from the Prada show in Milan”—that was the opening line from a piece on NPR. Apparently this year’s runaway hit on the runways has to do with high heels, with the emphasis on the notion of high.

The following comes from the UK Telegraph: The girls looked like rabbits trapped in the headlights; their faces taut and unsmiling, their eyes wide with fear and apprehension. Were they about to undertake a parachute jump? Abseil down a 1,000 ft mountain? None of the above. All they were doing was trying to negotiate the catwalk at Prada during this week’s Milan fashion shows in shoes that were virtually impossible to walk in. At least two models tripped and fell on to the concrete floor; others wobbled and stumbled, teetering and tottering, clearly in agony, and all the while their minds were fixated on just one thing: reaching the sanctuary and safety of the backstage area without suffering a similar fate.

According to the NPR reporter, the heels are so high that regular people—women people that is—can’t seem to walk in them without falling. This problem has led to the creation of an entirely new micro-industry. In L.A. and New York, there are classes to teach ladies how to walk in very high heels without hurting themselves. These classes are being offered through dance schools that couldn’t fill their dance classes—they are now booked solid.

Tell me this isn’t the same as trying to walk and chew gum at the same time. Multitasking.

Now before I make fun of some thirty year-old who has to relearn how to walk, let us turn our attention back to those dancing—cum—walking schools. What makes this story interesting is that those dancing schools saw a need and re-engineered a part of their business to meet that need, sort of like we’ve been discussing regarding the need to improve patient satisfaction in your hospital.  With everything going on in healthcare, many things will change.  If they don’t require change, you probably have not been paying close enough attention. 

What’s important are having a plan to define what needs to change and managing the change.  Assess business processes, remove outdated duplicated processes.

Now I’m going to go saw the heels off my wife’s shoes before she hurts herself.

 

Patient satisfaction should be exclusive…to everyone

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Sometimes it feels like I fell out of the stupid tree and hit every branch on the way down.

Important: Do not remove the wires from your old thermostat until you have marked them with the enclosed labels.

This warning was printed on a bright red background with yellow text and hidden away in the middle of the adult-proof ballistic packaging of the new thermostat.

“Why didn’t you read the directions before you disconnected the old thermostat?” My wife asked as soon as she realized the fan was not working.

“Is there a reason one of the plants in the garden is on fire?”

“You have to power-wash the deck before you put the furniture on it.”  This is the heavy, metal outdoor furniture I am forced to carry indoors once the weather turns cold so that it can hibernate, and return it to the outdoors in spring. 

All my explanations about the fact that the furniture was designed for the outdoors and that it will outlast the next dinosaur ascendency go unheard.  It is this same furniture for which she has militaristically drilled the family, with the rigor of nuclear submarine crew trained to extinguish fires, to race indoors with the cushions whenever rain is expected anywhere within the lower 48 states.  Perhaps she read somewhere that if the cushions get wet they will suffer the fate of the Wicked Witch of the West and melt.

Responses are neither required nor expected of any of the questions or statements tossed at me.  To do so would be akin to arguing in a vacuum—as opposed to with a vacuum.

Pearls of wisdom, in my case, tossed amongst swine.  “Mongo just pawn in the game of life”—Mel Brooks, Blazzing Saddles.

The world has changed.  Customers have changed. All businesses have changed the relationship between themselves and their customers. With few exceptions, healthcare has not changed its approach to patients, and nobody seems to own up as to why.

The way the business model used to work is the business pushes communication from the business to the customer. Businesses evolved to the point where communication between the business and the customer became a push-pull model. The business pushes something to the customer.  Sometimes the customer pulls information, and sometimes the customer pushes information to the business.

Most pushes and pulls function on a one-to-one basis; the business to a single customer (patient), and back. It occurs in secret. Customer A was never aware of the push-pull between the business and Customer B.

Communication is no longer secret. In fact, it is anything but secret, especially among customers.  As the number of customers increases, their communication about a business can go quickly viral—not between patients and the hospital, but among patients. 

Hospitals can do a lot of things but they cannot put the toothpaste back into the tube.

I think patient satisfaction should be exclusive…to everyone, but then I have been accused of trying to believe in as many as six impossible things before breakfast.

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Patient Satisfaction: Still buying Data and Coaching, Why?

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Think about the answer to this question, how many nights have you spent in a hotel in the last decade?  For most of us the answer is more than one hundred.  How many nights have you spent in a hospital in the last decade?  For most of us the answer is probably between none and ten.  So then, when you go somewhere to spend the night and have your meals delivered, from which organization do your expectations about being satisfied most likely come?

Patient, customer. Hospital, hotel. Tomato, ta-mah-tow.  For those who want to argue that there are no similarities feel free to continue to do so.  For the rest of us let us look at how to improve patient satisfaction.

A few days ago I spoke with a hospital CEO about his efforts to improve the patient experience and about patient satisfaction.  He said that for years his hospital has spent a lot of money buying all sorts of data about their patients’ experiences.  The problem he said is that the company providing the data never did anything more than sell them the data.  So they kept getting all of this data but never saw any improvement in their patients’ experience that could be tied to the data they purchased.

That hospital has also hired coaches in the belief that this would help improve the experience.  The results were the same.

I asked him why he kept spending money when the expenditures failed to deliver the desired result.  He replied that the two things he knew he could do that would yield the greatest and most immediate increase in patient satisfaction would be to increase the number of parking spaces and to improve the food service.  Did he learn that from the survey data or from the coaching?  Nope.  He learned that from his patients’ family and friends.

Four rules worth remembering:

  1. Experience and satisfaction are related but they are not the same.
  2. Every patient has an experience but the experience does not always result in a satisfied patient.
  3. Patient satisfaction cannot be improved without knowing a patient’s expectations.
  4. Purchasing data and paying for coaching do not change rules 1-3.

Having thousands of data points comparing how your hospital is performing against other hospitals gives you a report card; it does not improve either the patient’s or patients’ experience. Coaching employees probably will not improve patient experience.

It is not the employees that need fixing.  Broken, outdated processes result in dissatisfied patients.

Patients have multiple points of contact with the hospital; before they are admitted, while they are in the hospital, and when they go home.  If you can answer the following questions you have a basis for improving patient satisfaction.

  • Which points of contact have the greatest impact on patient satisfaction?
  • When did anyone last ask patients to define their expectations?
  • Which points of contact affect most of your patients?
  • Which points of contact are frequented most by your patients?
  • What are the consequences of not knowing these answers?

The answers to these questions do not require purchasing data, nor do they require coaching.

Two highly frequented points of contact are your website and your call center.  Go to your web site and try to complete a simple task—schedule an appointment, or try to understand your bill—taks that might be done by a patient or by a patient’s family member.  Could you do it?  Were you satisfied?

Now dial the call center and ask the person who answers the phone a question about Medicaid or Medicare billing.  Could that person give you the correct answer?  Could the person they transferred you to give you the correct answer?  Did the recorded voice telling you to call back between the hours of eight and five give you the correct answer?  Were you satisfied?

If you were not satisfied, why would you expect your patients to be satisfied?  Satisfaction has everything to do about processes and customer service.  Data and smiles do nothing to improve broken processes and poor customer service.

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What if hospital business models weren’t so tribal?

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Twin sons of different mothers.  The judgment of Solomon, splitting the baby in half.

Healthcare providers.  Permit me the literary license and allow me to cleave the baby in half as follows:

  • The business of healthcare—how the business is run
  • The healthcare business—the services delivered

I tend to look at it from the perspective of the business model of many hospitals.  What is the delivery model is viewed as a 2.0 model and the business of healthcare, how it is run, is viewed as an 0.2 model. How does one transform a 0.2 business model to function in today’s, let alone tomorrow’s, changing healthcare model?

The delivery model of healthcare, the healthcare business, in juxtaposition to the business of healthcare, would never quarter to the idea of buying millions of dollars of technology without first knowing how they were going to use it.

Plenty can be gained by applying what other industries have done to become more effective, more competitive.  In some respects the inherent model, tribal, cost duplication, and rigid departmental silos remind me a lot of how the various agencies under Homeland Security functioned, operating in isolation, performing much of the same work, and not sharing information.

Other industries operate with a much less tribal model than healthcare.  Hospitals have created tribes and tribal chiefs.  In some hospitals the tribes have names like radiology, general surgery, psychiatry, and OBG/YN.  Other hospitals have redundant tribes named admissions, human resources, IT, and payroll.  Each tribe is run by the tribe’s chief.  The chief’s dominant weapon is his or her budget which is lorded over its individual tribe, and a dispute vehicle with the other tribes.

The tribal organization is more a reflection of how the hospital evolved over the years, not a result of an inept business strategy.  Nobody set out to build an ineffective and internally competitive model, or one that duplicated support functions.  Acquisitions have reinforced and exacerbated the problem, duplicating and increasing costs without yielding a resultant increase in value.

Providers have to interact with and depend upon unknown influences of external influencers that each carry a much bigger stick than do they—payers, pharma, and Washington.  Before the business of healthcare is prepared to cope with the unknowns of the myriad of external influences it will face in the next few years, it must first change how it functions under its current structure.  It might begin by revisiting its present structure and making sure that its performance and quality precede the application of technology.

I frown on using the term efficient.  To me, efficiency implies speed, and doing bad things faster is no solution.  Let us work at improving effectiveness and good things will happen.

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Why your Website is Killing Patient Satisfaction

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Hospitals probably have more than one hundred points of contact with each patient.  These points of contact (POCs) begin before the patient is admitted and continue after the patient has been discharged.

The first contact may come by a visit to one of the hospital’s clinics, a 3 A.M. call to a primary care physician, or browsing the hospital’s website.

Yesterday I assessed whether the website of a large hospital group was functional or whether it was just a website window-dressed to look like a customer portal. I assess functionality based on whether I was able to accomplish what I set out to accomplish.

I counted dozens of different phone numbers to call. Along with the list of numbers were links for physician and employee portals, links to the board, a link for donors, wellness, specialties, medical professionals, and dozens more, all on the front page. 

There was even a link, albeit not a portal for patients—a rather important link since the number of visits by patients and prospective patients probably greatly exceeds the combined number of visits by all other visitors to the site.  Unfortunately the patient link was imbedded with six other equally weighted links.

I clicked the patient link and was greeted by two-dozen new links, each displayed as being of equal importance.  There were links for patients to use before coming to the hospital and links for them to use once they were home.  Points of contact with your hospital.  Points of satisfaction or dissatisfaction. 

I clicked some more.  Schedule an appointment.  There are actually two links for scheduling an appointment.  The first link gave me a phone number I could call M-F between 8 and 5:30 P.M.  What number do I call at 6 PM I wondered?  I tried the second link; it took me to the same place. Could I schedule an appointment online or through a mobile device?

What did I learn? There are 168 hours in a week.  Their scheduling service operates for 47.5 hours a week, 28% of the week’s hours. If I dialed that number after hours would I get a recording telling me how important my call was?  If my goal was to schedule an appointment using their website, or to schedule an appointment at any time on any device not only did the hospital not meet my expectation, it did not even offer me an alternative. A dead-end.

If it costs the hospital thirty dollars to schedule an appointment by phone and nothing to schedule an appointment online, why not complete the task correctly, the first time, and for zero cost?

I next looked at what I could do when I was home, more POCs, more chances to be satisfied or dissatisfied. 

Manage my medical records. Using the website I was able to print and mail, two very non-electronic processes, a request to have my records printed and mailed to me.  There was no way to submit my request using their website.  If I did not own a printer or did not have access to a printer my expectation was not met, and was I not offered an alternative.  Some people, a whole lot of people, actually like to complete tasks using a tablet or smart phone. Another dead-end.

Let’s try billing. For Medicaid patients there are two numbers to call for help understanding your bill. That means understanding Medicaid bills is a nontrivial exercise.  That tells me that if I asked the same Medicaid billing question of three different people I might expect to get three different answers.  Why not design the sight so that it provides one right answer to whatever question is asked?  Why not include an online chat feature? Why not create a link to a YouTube video, produced by the hospital that explains Medicaid billing?

Medicare.  No link to prequalifying, not even a phone number for questions.

How to pay your bill.  Perhaps the most difficult and least desirous task a patient must do. There is no link explaining the various components of the bill, and nowhere on the site is a copy of a sample bill explaining or highlighting the various sections of the bill.

There is also no link to understand how to file a dispute or a claim with a payer.  Maybe it is not possible to do this for every payer, but using the 80:20 rule there must be ways to help the majority of patients understand what they are up against rather than having them face down the evil empires on their own.

Patients come to the hospital’s website with expectations.  Patient satisfaction is repeatedly won or lost at your hospital’s website and on the phones.  POCs.  Having a tool that proposes to help patients with their bills that not only does not help them but that adds to their frustration will crush patient satisfaction.

Hospitals want patients to pay their bills and to pay them on time.  Patients who do not understand their bill will not pay more completely, nor will they pay faster.

The next time you look at your hospital’s website ask yourself how different it would look had someone asked a patient how it should function.

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Why Patients Lose Patience

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Who is responsible for patient satisfaction?  The flaw of averages suggests that the buck does not stop somewhere.

Your amygdala’s been hijacked.

The bad thing about being a former mathematician in my case is that the emphasis is on the word former. Sometimes I’m convinced I’ve forgotten more than I ever learned—sort of like the concept of negative numbers. It’s funny how the mind works, or in my case goes on little vacations without telling me. This whole parabola thing came to me while I was running, and over the next few miles of my run I tried to reconstruct the formula for a parabola. No luck.

My mind shut that down and went off on something that at least sounded somewhat similar, parables. That got me to thinking, and all of a sudden I was focused on the parable of the lost sheep, the one where a sheep wanders off and the shepherd leaves his flock to go find the lost one, which brings us to where we are today.

Sheep and effort.  Let’s rewind for a second. Permit me to put the patient lifecycle into physics for librarian style language—get the patient, treat the patient, lose the patient.  These are the three basic boxes where providers focus resources. How do manage the patient lifecycle to our advantage? We have marketing and sales to get the patient, we have patient care to treat the patient.  Can anyone tell me the name of the group whose job it is to lose the patient?  Sorry, I should have said to not lose the patient.

Patient retention.  Can anyone in your hospital tell me what specific efforts are underway to get patients to return the next time they need care?  I hope it involves more than the marketing department erecting another billboard with a picture of the urologists.

Where do most providers spend the majority of their intellectual capital and investment dollars? Hint—watch their commercials. It’s to get the patient. Out comes the red carpet. They get escorted in with the white glove treatment. Once they’re in, the gloves come off, to everyone’s detriment. Nobody ever sees the red carpet again. A high percentage of a hospital’s marketing budget is to get the patients. Almost nothing is spent to retain exiting patients.

Existing patients versus exiting patients. Why patients lose patience. 

Winning hospitals roll out the red carpet when patients exit. They do this for two reasons. One, it may cause a patient to return. Two, it changes the conversation. Which conversation? The one your patient is about to have with the rest of the world. How does your hospital want that conversation to go?

What do you have to do to get the patient to come back the next time he needs treatment? What the next visit of a patient worth to your hospital?  What about the next five visits? There seem to be a lot of questions for which answers seem to be missing.

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