What Happens When Patient Experience Encounters Spiderman?

I had some questions for my provider.  That is not accurate, I had a bunch of things I needed to accomplish, and questions I had been saving up for the simple reason that I did not want to put myself through the process of interacting with the hospital multiple times. I thought it might hurt less if I did them all at once.

Some of the things and questions on my provider to-do list included:

  • Scheduling a follow up appointment
  • Refilling two prescriptions
  • Setting up a payment plan for myself
  • Learning how to file a dispute with my payer
  • Getting additional information regarding my discharge orders
  • Learning if there was a way for me to add personal health data to my health record
  • Get a copy of my personal health record
  • Learning if I could track my vital signs, diet, exercise, and medications on their system.

I thought I would try get some of these sorted on the phone and others online.

As I was reveling that I was able to do all of these with a single call and a single visit to the hospital’s customer portal my wife woke me.

“You were having that crazy nightmare again, weren’t you?” She asked.

“What nightmare?” I wondered.

“The one where you suspend disbelief, and you go to that hospital’s website and do all of those things . You have that dream every time you wear your Spiderman pajamas. Tonight you wear your Flintstones pajamas so I can get some sleep.”

Patient Experience Meets Roemer’s Laws of Evolution

There are people who believe that to improve the effectiveness of a business you must belong to one of two camps; the business process camp where you get the same result every time—a structure for predictability, or the creative process camp where you get a different result every time—a structure for possibility.

Let’s look at the here-and-now.

Most businesses, including hospitals, have, according to Roemer’s Laws of Evolution—think Darwin without the bit about fish walking from the sea—processes in place that have evolved over time.  Individual processes have evolved from multiple ways of performing a task to a single way of doing a task.  Inefficient ways were eliminated, and we settled on one efficient—fast—way of executing a process. If we still do not like the process, we hire and expensive firm and squeeze out a few more seconds by using some form of twelve-sigma approach.

When we are done, what we have left is a process that is as fast as we know how to make it, a process by which we get the same result every time. We have created a structure of predictability.

The process may not even be necessary, and the results from the process may not be correct—think effective, but we have figured out how to make that ineffective process very fast. And after all, fast is good. Right?

Having arrived at this point in the process evolution process, we have arrived at a point of stagnation.  There is very little left to tweak, and the last person who uttered the words ‘change’ or ‘innovate’ in a meeting is now working as a barista at Starbucks.

That is why patient experience improvement efforts have stagnated. What inertia there was to improve it has become the inertia of passivity.

I am not arguing that having patient experience processes and patient access processes that yield the same result every time is a bad thing. In fact, I believe that result to be the goal; processes that do the same thing every time.  However, what would happen if a priori to this singular way of doing things we added a structure for possibility?  What if we allowed creativity into the mix?

For example, what if?

What if instead of asking how do we improve the process people experience when they call the hospital we asked—what if people did not have to call the hospital? Do you know why people call the hospital? They call because they have no other alternative to meeting their needs.  What if—and I know this borders on the edge of credulity—people did not need to call? What would that entail? What would the business look like?

What if instead of asking how do we improve the process people experience when they are admitted to the hospital we asked—what if people did not have to be admitted?  But what would we do with the waiting area, the admissions desks, and all of those outdated copies of Highlights Magazine, you ask. 

There is not rule that requires you to keep a process just because the process is efficient.

Eliminating a process yields the ultimate in efficiency.

Instead of shaving thirty-two seconds off of the time it takes to admit someone, why no eliminate admissions? What would that look like?

One of my consulting clients had seventeen call centers.  They asked me to help them create a call center strategy. At the kickoff meeting I announced we were going to operate under the assumption that we were going to close all of the call centers. One executives argued, “You cannot close all of the call centers because we receive over four-hundred-thousand calls each month about our bills.”

I replied, “At thirty dollars a call, you are spending $144,000,000 a year, each year, talking to your customers about your bills. Can’t you fix your bills for less than $144,000,000, or eliminate your bills?”

Once you get that process fixed make it repeatable, make it yield the same result every time.

What is the Patient Experience Gumball Postulate?

This is my gumball machine. There are many like it but this one is mine. Without me my gumball machine is useless—a paraphrase from Full Metal Jacket.

The gumball postulate states: Most times you will have a gumball experience that gives you a gumball that is not the color you wanted.

The only problem I have with gumball machines is that although you know you will get a piece of gum for a penny, you never know what color the gum will be until you have spent the penny.  There are eight colors of gum in my machine. I like the greens, yellow, and purples.  Hence, for any given turn of the dial I have a thirty-seven and a half percent chance of being satisfied.

At the outset, assuming there is an even distribution of the gumball colors in the glass jar, the chance that I will be dissatisfied with each expenditure of a penny is greater than sixty-percent.  Not great odds.

From the perspective of a customer, they know from their prior experiences that their experience of having to interact with any organization, with your organization, will be a whole lot worse for them than getting the wrong color of gumball.

But the principle is the same.  The experience doesn’t depend on anything that was planned. It does not depend on anything that was designed.  The quality of their experience, and their satisfaction with that experience depends on one thing—random selection.  Green gumball; red, white, or purple.

The healthcare postulate states: Most times you will have an experience that is not the one you wanted.

Now some of you will argue that your organization is committed to improving patient experience, and you will cite actions like employing a parking valet service, and improving the food in the cafeteria. It may be worth noting that the management team parks their cars and eats in the cafeteria, but maybe that had nothing to do with why those services were improved.

One thing the management team does not do is call the hospital. They do not know how many times someone has to call to schedule an appointment, to speak with a nurse, or to get someone to help them understand their bill.

A person’s (patient, customer) satisfaction when they call your organization depends on a combination of some or all of the following:

  • Was the phone busy
  • Were you placed on hold
  • Did the person you spoke with know the answer to your question
  • Was your call transferred to someone else who they hoped might know the answer
  • Did the person speaking with you know anything about you before they spoke to you
  • Did it seem as though the person had access to the right information to answer your question
  • Did you have to call multiple times to get the right answer
  • Did you have to speak with multiple people to get the right answer
  • Did you ever receive the right answer
  • Has this happened to you more than once

Suppose you were bold enough to call more than once, and that you asked the same question to each person with whom you spoke.  Would you get the same answer from each person?

Of course not. Don’t believe me; try it.

Do you know why people call your institution?  Try to write a list about why you believe people call. Hint: if your list contains fewer than twenty items, you probably do not know why they call.  And, if you do not know why they call, how can you possibly expect to answer their questions when they call?

So where are we?  We do not know what type of experience people have when they call, and we do not know why they call.  That said, can there be any doubt that what they experience when they interact with your organization is poor?

The solution to this problem is not a software package. Software is a tool.  The solution comes from knowing why people contact your organization, and knowing what they expect from your organization when they make contact. Without knowing the answers inside-and-out to those two items means the experiences will continue to be poor.  Once you know those answers you must design an experience that provides each person exactly what they want every time they call you or go to your website.

If you think that is impossible, go to the websites of Amazon or eBay. Look for a phone number to call that will allow you to speak with someone about anything; customer service, accounts receivable, customer returns, and shipping.

Is that because they do not want to talk to you? Is it because they do not want you to talk to them? Of course not. It is because they inventoried all of their business processes, and then they designed a way, one way, to ensure that each interaction was tailored to solve that business process the very first time the person needed it solved. They designed it so that it works for every business process and so that it works for every person every time and on every device.

Here’s a freebie for playing along.  Chances are good that the people who answer the phones at your organization do so only between the hours of 8 A.M. and 6 P.M. Monday through Friday.  Why not at least offer your patients and customers the same opportunity to reach you as Comcast and Verizon offer their customers?  That is a low threshold, but certainly not one your organization should be below.

Now if you have made it this far, you might suspect that I am a huge advocate of call centers. I am not. I am a huge advocate of the notion that says if you are going to interact with your patients and customers by phone that that interaction should be remarkable.

It is a lot easier to improve the gumball machine customer experience. All I have to do is use the key, open the top, and select the best experience.

The future for patient/customer interaction lies with self-service on the web. If you are interested, this link takes you to a PowerPoint deck that addresses that point.


Arrogant Socks and Emergency Department Wait Times

socksWriting a blog is the only affectation I know where sarcasm passes for intelligence.  Sometimes I find it helpful to leave a trail of breadcrumbs to help you see where the story may be headed; today I have decided to leave a trail of croissants.  That said, here we go.

Packing for my trip today I was interrupted by the obscure phrase, “Those socks are arrogant. There is a reason why most men wear plain, dark socks.”

“I don’t want to look like most men,” I said as I tossed them into my suitcase.

“If you wear that pair, you won’t look like any men.”

“Besides, socks cannot be arrogant,” I replied, ignoring her sarcasm, “any more than they can be disappointed. Socks can be cotton and Italian, as these are, and they can be colorful for the same reason, but they cannot be arrogant. Show me someone who has a bad thing to say about my socks and I’ll show you someone challenged by color.”

Every time we get into one of these conversations I feel like I am trapped in a veritable Tennessee Williams play, or like I am having a battle of words with Sigourney Weaver in Alien minus her automatic weapon.

“You know what I mean,” she said. For those of you who have your own sock monitor, you should be able to infer who she is. “Wearing those socks makes you come across as arrogant. The type of person who would wear those socks is the type of person who would walk into a Seven-Eleven and kill everyone because the Slurpee machine wasn’t working.” Sigourney get your gun. Wasn’t that a musical?

“I have a mind of my own.”

“I know,” my Sock Monitor replied. “It’s how you use it that keeps me up nights.”

“The socks make me a nattily dressed, confident and sartorial gentleman.” I felt like I was trying to explain cholesterol to a Big Mac. Maybe I needed to spend some time in a reeducation camp.

“Yeah, whatever you think they make you, do not wear them to your meeting tomorrow unless you want to be remembered as the guy with the leprechaun feet.”

I looked at her with the trepidation of a student teacher in a geography class trying to point out Burma on a dated map, and I decided to call this a draw before Ms. Weaver went for her weapon.

The IDN’s website displayed the waiting times for its five hospital emergency departments. Two of hospitals displayed wait times of “+60 minutes.”

Now I am not sure why I think the way I do about things. Maybe it means I don’t play well with others. Or, perhaps it reflects the fact that my thinking is so far off from being main-stream that my little billabong dried up a long time ago.

So, let’s look at the idea of posting wait times for a hospital’s emergency department. I imagine hospitals post them because someone suggested that doing so would improve customer experience. My question is, Cui Bono—who benefits?

Emergency: a serious, unexpected, and often dangerous situation requiring immediate attention. The definition, to my way of reading it, is unambiguous. Dangerous situation requiring immediate attention. Need we define immediate? Suppose you have one of those situations.  Which of these do you do?

  1. Dial 911
  2. Drive yourself to the hospital
  3. Log in to the hospital’s website to check the wait times at the emergency department, and then drive yourself to a hospital.
  4. Phone a friend and ask him to come over to watch the Eagles game with you.

Let’s take a minute to review your options.

If you dial 911, you do not have to trouble yourself with wait times because the ambulance driver will decide which hospital will treat you.  The EMT will not ask you about your insurance, and the driver will not consult you about your preference based on current wait times. In fact, you may not even be taken to one of the hospitals in your payer network.

If you drive yourself to the hospital, and your situation is really a dangerous situation requiring immediate attention, do you go to the closest hospital regardless of whatever the wait time may be? Or, do you start messing around with higher maths. Please play along.

Our Lady of Rapid Service is seventeen miles away and has a posted wait time of ten minutes. The hospital of We’ll Get To You When We Can is five miles away and has a wait time of forty-two minutes.

The real question becomes, “Which hospital has the lowest gross time before I can be seen?” (The lowest wait time does not guarantee that you will be seen sooner. Gross time equals the sum of drive time plus parking time plus wait time.) To answer this correctly requires that you include numerous other factors; traffic, road repairs, weather, time of day, curvature of the earth, and so forth. It also requires a bit of clairvoyance on your part.  The posted wait times are the current estimated wait times, not the estimated future wait times. The posted wait time would be helpful if you were at the hospital now, as in right now. But the wait time may be different by the time you arrive.

So chances are good that if you have the time to look up and evaluate wait times, and have time to select a provider based on those wait times, and have the additional time required to drive yourself to said hospital, the one thing you do not have is…say it with me… A dangerous situation requiring immediate attention. The concept of wait time flies in the face of the concept of immediacy. In other words, someone with all of this extra time on their hands probably does not have an emergency. 

Which, as it turns out, is what a lot of people who go to the emergency department do not have—an emergency. In which case those people should not be going to the emergency department, and if they do, perhaps they should be made to wait. Getting rid of those who do not have emergencies, or just making the non-emergency group of people wait in their own little queue, will make the wait times for those who have real emergencies so low that the hospital will not need to post wait times.

Which not only solves the problem, it makes the option of watching the Eagles game make a lot more sense.

Back the question I raised at the outset, Cui Bono from posting wait times?  The only answer I can come up with is that the people who benefit the most are the ones who do not have an emergency. An example might be the person who called their doctor on a Friday afternoon because they ran out of their prescription and they were told that they would have to wait until Monday for a new script.  This person calculates the drive-time/wait-time math and picks the hospital that will get them home with the least amount of interruption to the Eagles game.

Bonus round. Now, for extra credit, how would having a triage nurse available at the hospital’s call center impact ED wait times? It would bring them down because many of the people whose needs were basic, those people who did not have an actual emergency, but who needed a new script or medical advice, could be served by speaking with the nurse. This would bring down wait times, reduce costs, improve patient experience, and allow more people to watch the game or do whatever it is they would have done had they not been waiting in the emergency department.


What Can Hospital’s Learn From Chuck E. Cheese?

chuckI thought about having the meeting at the Westin, but instead chose a place across the street that was a little more upmarket. I left my keys with the valet and headed inside. The lobby was built around a three-story atrium whose center piece included a tiered waterfall garden. A brass plaque indicated that the floor was made of inlaid Carrara marble from Italy. A pianist was playing one of Beethoven’s etudes on a grand piano that had a sheen so brilliant it made me wish I had taken the time to have my shoes shined.

I purchased a half-café, double espresso, machio-something-or-another, and made my way across the inlaid marble to a leather settee whose leather was finer than the seats in my car.

As I waited patiently for my guest, I was reminded by the sign next to the reception desk that cardiology was located on the second floor. Perhaps I should drop by later to say hello to my cardiologist.

Ever wonder why hospitals pay so much attention to how their lobbies look? We know that once we walk through the set of double doors, or head down one of the many hallways with their wayfinder colors painted on the linoleum tile, the look and feel of the lobby disappears.  Whether you are a patient, a visitor, or an employee, the amount of time you spend in the lobby is fleeting compared with the amount of time you spend in the hospital. And yet, there it is. Spacious, inviting, ornate, and gleaming. It almost pleads with you to stay and enjoy your experience.

We know that all of that money and floor space for the lobby must have been allocated for a reason. We know the architect didn’t look at the plans prior to submitting them to their client and say, “Whoops. We forget about designing something for this extra twelve-thousand feet of space. They will notice this goof. I know, let’s put in a big lobby.  And with all of that extra money we have, let’s snaz it up a bit.”

A lobby exists to lobby you into believing that what lies beyond the lobby is equally enticing, that the lobby is just the prelude to what comes next. Maybe that is the same feeling Dorothy and her friends encountered as they passed through the emerald gates. It should be noted however that Dorothy’s wonderful experience was fleeting.

It may be an interesting exercise for a provider to count the number of people who visit their lobby, and then to count the number of people who go to their website and who call the hospital. The website visitors and the callers will greatly outnumber those who pass through the lobby.

And what of their experiences? What would they tell you about those experiences?

What remains important about any experience is the willingness of the individual to have the experience more than once. If they have a horrible experience on the phone, the likelihood of them ever calling again falls precipitously.  Think about your hospital’s website. Can you think of a reason that would entice someone to go to it more than once? Since there is nothing for them to do on the website other than to read about the hospital, is there a reason for them to return to it? If there isn’t, shame on your organization for wasting all of those digital 1’s and 0’s. The hospital’s website is the hospital’s most visible business tool. Unfortunately, its lack of functionality does not make it the hospital’s most valuable business tool.

To adults, hospital websites are healthcare’s version of Chuck E. Cheese; one visit is enough.

Nota bene—the Chuck E. Cheese website is probably a lot more functional than the majority of hospital websites.

What Patient Experience Could Have Been

Whether one is running at windmills as a quixotic muse, or trying to bisect an elephant with a licorice whip, to anyone observing those actions it makes no more sense than having a lint collection.

Example 1: Let us say that someone walks into a nail salon and requests a manicure and a pedicure. The salon’s owner says “We only do manicures here. You have to go across the street for a pedi.”

You get the manicure, and as you are leaving the owner asks you to complete a survey about your experience with her establishment, and then she asks you to recommend your friends.

Example 2: You call the company who provides your cable television, your internet, your wireline, and your mobile service to tell them that your cable is out and that you have a question about your wireless bill.

As you wait on hold you hear the message repeated over and over for forty-five minutes that this call may be recorded for quality purposes. When you are finally afforded the opportunity to speak with a hominid about your cable outage you are told to call the cable service number. When you ask about your mobile bill you are told those questions can only be answered between 8 AM and 5 PM Mondays through Fridays. As you are about to explain that it is 10 AM on Tuesday the operator disconnects the call.

Within a minute you receive an email from the firm asking if you would complete a brief survey about your experience with them

Example 3: (stop me if you see where this is headed) It is 6 AM. You are going to be charged for parking.  You have passed through a lobby that is as ornate as anything in one of Dubai’s finest hotels.  You and the lemmings are seated in the admissions waiting room alone.  Each of the admittors (first-person singular present passive indicative of admittor–I had to look that up) is sipping from their mocha cappuccinos. You are not because you have not been allowed to have anything to drink since the last republican administration.  As you sit and wait for your turn to be admitted you are reminded of the last time you were at the DMV to have your driver’s license renewed.

A single television, which seems to be tuned to al Jazeera, is suspended overhead.  As there is no wifi, your only other option for killing time is the copy worn of Highlights magazine announcing the upcoming 1969 moon landing.

You complete the admissions process, finally.  You ask to receive a copy of the hospital’s customer experience survey, an opinion form, or whether they have a comments box.  Check D—none of the above.  When you ask why you are told, “Mister this is a hospital.  We make you better.  That is the only experience we care about, and it should be the only one you care about.”

As the anesthesia enters your blood stream, instead of counting backwards from infinity, you are left wondering why you couldn’t self-admit the night before using your iPad.

Example 3 could also been an example of someone trying to schedule an appointment online or through the call center. It could have been someone requesting the medical records. It could have been someone trying to understand Medicare. It could have been someone trying to pay their bill. It could have been someone deciding where to buy healthcare. It could have been someone seeking a second opinion.

What hospitals do not understand is not that it could have been all these someone’s…it was and it is.  Every day more people ‘visit’ your hospital online and on the phone than walk through the Dubai lobby, and nobody is asking them about their experience.

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

I may be wrong but I doubt it.

Do EHR vendors have a built-in bias?

I write from the perspective of hospitals and physicians who are required to pass tests of certifiable, meaningful use, and interoperability. As would be expected, comments made by EHR vendors are quite different from miine.   Forgive me for stating the obvious–their job is to get you to buy what their firm sells, to make you a believer.

There are more than four hundred firms who have something to sell you, something they believe will make your life better. How do you know which one of them is offering something that may work for you? How can you tell? Heck, how can you tell which product will still be viable in three years?

A question worth considering.  As passionate as the vdenors’ sales reps are, when a sales rep moves from Vendor A to Vendor B, does their passion remain with Vandor A?  Of course not.  The new “best thing since slided bread” is the thing offered by Vendor B.

Where does that leave you?  For starters, don’t buy it on faith.  Don’t buy it just because somebody else bought it–is their judgement better than yours?  You need a way to make an objective decision about some very subjective information.  One way to do that is to turn the subjective issues into quantifiable business requirements.

What do you think?

Don’t let DC drive your selection process

The decision to do EMR/EHR should be made independently of Washington. There either is or isn’t a valid business reason for going forward.  ARRA funds and penalties are not valid business reasons unless perhaps you operate a very small practice.

I believe there are valid reasons. I also believe that without knowing which of those reasons suite your organization there is a strong possibility of selecting the wrong system.