How To Recognize Awful Experience

I finally had my chromosomes mapped. It should not come as a big surprise when I tell you that I lacked the chromosome for patience and had a duplicate of the chromosome that is most closely associated with cynicism.

Nota bene. I am on my eighth American Airlines flight in the last two weeks. Each of them has been delayed by at least an hour and a half.

Water off a duck’s back. For some, perhaps. But, I’m not your average mild-mannered duck.

And so on the last of my eight flights I pulled out two sheets of paper, one sheet for each side of the plane. Across the top of each page I wrote, “List three things that you would do if you were an executive of American Airlines to improve the flying experience.”

And off they went to Row 1, seats a through C and Row 1, seats D through F. By the start of Row 4 I had received a request for more paper. I hired a small child who was seated across the aisle from me to be my courier. Back and forth he went, dispensing blank sheets of paper and retrieving the completed sheets. On his second trip forward his return trip was delayed.

“What took you so long?” I asked.

“A bunch of people wanted to make videos of their experience,” he told me. “And I had to show someone your age how to Instagram their trip.” (My age?)

I looked up and saw a flight attendant marching posthaste towards me. She was carrying several sheets of paper. The ammonium nitrate was about to hit the oscillating air device.  I gave her my best smile and a wink.  She looked me in the eyes and said, “The captain asked if he was permitted to share his recommendations.”

The wink gets them every time.

Flying.  Bad experience.  ‘Nuff’ said.  The blog could end here.  Healthcare reform could end here.  Neither one will happen.

Most airlines offer two types of seats; first class and no first class – steerage.

First class exists for only one reason—to let the rest of us know that we are not in it.  Airlines hang a shower curtain between first class and coach.  They do this to make it clear to those of us in the bleacher seats that everything beyond the curtain is off limits.  But they do make passengers flying coach walk through first class to get to their seats.  Now each coach passenger has a barometer to measure just how bad their experience is.

“Don’t even think about storing your bag there,” she notifies me.  “This bin is reserved for our first-class passengers!”  Blocking me with her body, the flight attendant turns to the person in seat 2A and asks “May I hang your jacket, sir?  Would you mind if I refill your Crown Royal?  Be sure to leave room for dinner—we’re serving steak and lobster tonight.”  I wished I had purchased the thirty-dollar bag of Gummy Bears.

The bad experiences of coach class are particularly bad simply because first-class exists.  If there were no first class, flying coach would not be so a bad because we all suffer together. Southwest Airlines figured that out.  They do not offer first class.  And despite that, they are always among the highest rated airlines for customer experience.

Healthcare patient and customer experience.  How good was yours?  The scoring is binary —a 1 or a 0.  You either sat in first class or you sat behind the shower curtain.  Did your healthcare experience compare to having surf-and-turf, or did it make you wish you had bought the Gummy Bears?

Bad customer experiences are not insoluble.  Very little is.  For most companies, bad customer experiences are simply a failure of imagination.  For providers, their failure of imagination comes at a high price: poor care management, lost patient acquisition, and poor patient retention. And if that is not a real mess, it will do until the real mess comes along.

Just so you know, none of us likes flying coach.

His Name Was Ed

You don’t have to read this. But I had to write it.

He was a man nobody would write about other than someone to whom he meant the world. One of his final requests was to be buried alongside other veterans in the national cemetery in Florida.

He served in Japan as part of the occupation force after World War II. He never faced combat. He wasn’t an officer. Nor was he a corporate executive.  He wasn’t a first responder. He didn’t run into burning buildings. He wasn’t thought of as exceptional.

He was a civil servant. After leaving the military he worked for thirty-five years at one of the federal agencies in Washington D.C. It was an agency whose name the employees never mentioned.  In fact, its employees were simply told to tell others that they worked for the Department of Defense.

He was my dad.

On those days in elementary school when the children were told to talk about what their fathers did for a living, I didn’t have much I could tell about my dad. I thought about lying and saying my dad was a pilot or that he played baseball. But my friends and I collected baseball cards and none of them had ever seen my dad’s picture on a baseball card.

I only knew three things about what my dad did for a living. First, every so often the FBI would talk to our neighbors and they would ask them if they knew what my dad did.  The only acceptable answer was ‘no.’ Secondly, although he carried a briefcase to and from work—the briefcase only contained his lunch. He wasn’t allowed to bring any documents home.

Oh, and he was fluent in Russian. Fluent in Russian at a time when my friends and I and millions of other students were taught what to do in the event of a nuclear attack.  An attack by the Russians—his Russians.  We practiced ‘ducking and covering’ under our desks. Call me crazy, but I never held much belief in the efficacy of ducking and covering.

Even though when I was in college I held a top-secret security clearance, to this day I still don’t know what he did but that has never stopped me from embellishing the narrative of his life. I may have occasionally implied that he left rolls of microfilm tucked behind a loose brick in the southwest corner of the wall of the Metropol Hotel across the street from the Kremlin.

I prayed on the plane. Hard. My only request was that he would still be alive when I arrived at the hospice in Florida from the airport. ‘He keeps asking if you’re here,’ my mother had told me prior to my flight.  I shared my concern that I would arrive too late. My friends told me that he would wait for me to arrive.

And he did wait. I held his hand and told him I loved him. With eyes that were no longer seeing he brought my hand ever so slowly to his face and he kissed the back of it and then he pressed it against his cheek. I prayed with him.  I’m not sure that he heard the prayer, but I knew God heard it. I leaned close and I told him that it was okay for him to go.

A veteran of the Vietnam War asked permission to enter my father’s room. In remembrance of my father’s service, the veteran presented me with a star that had been cut from an American flag. He gave my mother a certificate acknowledging my father’s service. The veteran turned smartly and saluted the unseeing man who lay motionless in the bed and said, “Soldier, on behalf of a grateful nation, thank you for your service.” That was as ‘proud to be an American, goosebumps moment’ as I ever had.

My dad died this morning. His death won’t be written about. It won’t be reported on television. Flags will not be lowered to half-mast.  His death will not create a Butterfly Effect. The world will not skip a beat.

My heart did.

My dad was the most honest and decent person I ever met. I never heard him swear. I never saw him drunk. I never saw him deliberately choose to do something that was not right.  Everything that is good about my character, my faith, my integrity, and choosing to do what is right, I got from my father. My failures and failings are of my own making.

They say you are not really dead until no one ever again says your name. This Father’s Day, if you can, talk to your dad. When my three children think of me I hope they see my dad. His name was Ed.

A healthcare footnote:

The week before he entered the hospice he entered the hospital. His pulse was 120. They gave him an MRI. The authorization form asked him to indicate whether he had any kind of dental plate. He wrote that he did.

The hospital performed the MRI and took my father back to his room. They were going to discharge him that afternoon. But he refused to eat and drink and take his medicine. He refused for 15 hours.  Instead of telling the nurses why he refused he made loud guttural sounds. And when he refused he kept pointing to his mouth. Finally, my mother looked in my father’s mouth and she saw that the tip of his dental plate was barely visible in his throat.

He had aspirated the plate during his MRI, the very same plate that he had told them about on the authorization form. They took him to surgery. The next day there was no discussion of discharging him. The hospital was now recommending that he enter a rehab facility. My mom, who is also 89, spent the day visiting rehab facilities. She found one close to their home and began the admitting process.

Two more days passed. Gone was the discussion of moving him to a rehab facility. His doctors now agreed that my father, the man with a high pulse, should be moved to a hospice.

When he arrived at the hospice, his pulse was normal. If that sounds cynical, that was my intent.


My Healthcare Consumerism Podcast

The Myers-Briggs personality profile test concluded that I am an INTJ—the ‘I’ means I am an introvert. The NTJ means I make Napoleon seem like a pacifist. Anyway, I think I mentioned that I moved to Portland, Oregon in January. I’ve learned a lot about mosses.

Wanting to connect to my new community, I, the introvert, decided to audition for the play Inherit the Wind. I should mention that the last time I was on stage was in college. I auditioned for a play my junior year in high school. Because I didn’t get the lead I quit. I got the lead my senior year.

The audition in Portland required me to perform a monologue and a song. As a person of unlimited hubris and believing that I am not an introvert, I chose to sing ‘Bring him home,’ from Les Mis—if you are going to make a fool of yourself you might as well shoot the moon.

For the monologue I memorized three well-known courtroom scenes; Al Pacino’s closing argument in And Justice For All, Jack Nicholson’s testimony in A Few Good Men, and Matthew McConaughey’s closing argument in A Time to Kill. Go big or go home.

The result of my audition? Not only did I get a part, not only did I get the lead role, they are going to pay me to perform. The world gets curiouser and curiouser.

My days of being an introvert are over.

No segue.

Healthcare Compliance Solutions invited me, as a subject matter healthcare consumerism expert, to be interviewed for a podcast.  In the podcast, I discussed the issues around how to improve consumerism, access, and engagement for all health stakeholders to drive accountable care, population health, and wellness.  Here’s the link:

If A Customer Falls In The Woods

So, I’m about to take the test to get my Oregon driver’s license. Unlike the other forty-nine states, the Oregon test gives the applicants a chance to earn bonus points or to lose points. If you have a tattoo, add one point to your score.  Body piercings are worth one point.  Green, blue, or purple hair is also worth one point.

If you voted for Trump, subtract five points. I was at negative five points before I answered the first test question. Knowing I had nothing to lose, I stood in the middle of the room and yelled, “Make driving great again!” Minus two more points.

A man who works at a manufacturing plant that makes items for hardware stores is suspected of stealing from his employer.  Because he is under suspicion, each night he when leaves the plant, the guards search him and the wheelbarrow he is pushing.  In the wheelbarrow is always his lunchbox, thermos, hardhat, safety glasses, and overalls.  They never discovered any stolen property.

It never occurred to the guards that the man was stealing wheelbarrows—sometimes the answer is too obvious.

Customer experience is a bear.  Sometimes you eat the bear.  Sometimes the bear eats you.  If Comcast’s or Verizon’s customer service people went on strike, would anybody notice?  Sort of like the question, if a tree fell in the woods, and nobody was there, would it make a sound.

The front-page banner on a recent issue of Men’s Health Magazine read, “Tons of useful stuff.”

In healthcare, none of the provider or payer websites or apps can even brag, “Here’s a half-dozen things that may be useful.”  To be even more accurate, the only four semi-useful things I’ve found on healthcare websites are:

  • Pay your bill
  • Find a doctor
  • Requestan appointment
  • Contact us

A pretty lackluster set of functionalities.

Your website may look pretty, but so does Monet’s painting Sunflowers.  The thing is, you can’t schedule an appointment with either of them, so pretty isn’t worth much.  If you’re confused, that’s okay, I’m not.

Patients and customers can find a cloud in each of what your health system believes are its silver linings.


Musings of a Drive-By Mind

downloadMany thanks to those of you who have been such steadfast followers over the years of my regurgitations of the gossamer voices which continue to disrupt my waking moments.

It’s statements like that which explain why so many clinical psychologists continue to read my musings. Apparently, several them are in an online chat group whose singular mission is to assess my mental acuity.  There’s a specious rumor being floated that the oddsmakers in Las Vegas are taking bets as to whether I am an idiot savant or just an idiot.

I started running again last week after four months of waiting for my meniscus to heal. Normal humans would probably start off slowly; run a minute, walk a minute. But it appears that Mr. and Mrs. Roemer raised a particularly hardy breed of idiot—I did 8 miles today. I was encouraged by the fact that I almost passed a ninety-year-old woman.  Even though she smoked me during an uphill part of the run, I was comforted by the fact that I looked good in my running uni and Ray Bans.  By the time I finished the eight miles, every part of my body hurt so much that I couldn’t even tell that I had a meniscus.


The woman walking from the hospital should have been watching where she was walking rather than speaking on her phone.  She did not see the sinkhole until she fell into it, at which point she could see it in detail.  The doctor, upon seeing her in the hole asked if she was okay.  Learning that she was in pain, he wrote her a prescription and dropped it and a pen into the hole.

A few minutes later the hospital’s director of revenue assurance walked past the hole.  She too inquired about her health.  He opened his briefcase and dropped an insurance claim form into the hole.  You should complete the form, but I don’t think having fallen into a sinkhole is covered under your plan.

The chief patient experience officer happened upon the woman and wanted to know what had happened.  Speaking with her for a few minutes, he asked the woman: how was your experience with us prior to falling in the hole?  “Would you mind filling out this patient experience survey?” He asked.  He tossed the survey and a pen into the hole and left.

The woman considered her predicament.  She thought, at least I can occupy my time by filling out the forms until I am rescued.

A consultant looked in the hole.  He went by the moniker, the Voice of Reason.  (You can buy Voice of Reason t-shirts during the intermission.)  He assessed the situation and jumped into the hole.

“Now we’re both stuck,” she said.

“That’s okay,” I told her.  “I’ve been in this hole before and I know the way out.”

If you try to recast consumerism and access and engagement and experience on your own, you may find yourself in the same position as the woman.  A lot of meaningless assistance.

My experience tells me that most efforts to improve consumerism are done without any knowledge of what their efforts should look like when they are done.

Here’s a big hint. If you design it correctly, and you must design it, it should not look like anything.  Consumerism, access, engagement, and experience should be ninety-nine percent invisible to your patients and consumers.

That ninety-nine percent should all be behind the scene.  It should be built into your consumerism architecture and platform.  The one percent seen by the patients and consumers is the hands-on user experience.

It helps if you think of it this way. Consider your tablet or phone and the underlying operating system—iOS, Android, and Windows.  Your devices are easy to use.  Their use is intuitive. What you see is the one percent.  Far more than ninety-nine percent of what makes them easy to use is invisible.  The hardware, the architecture, the processes, and the applications were designed.

And users were involved in every step of the design. It is called human-centered-design. Users knew the design would meet their needs and be simple to use before a single line of code was written.

The good news for healthcare consumerism is that a lot of the challenging work has been done for you.  The devices and the operating systems already exist.  The only remaining task is for healthcare to define what it wants to do with those tools.

Healthcare can design an experience for patients and consumers on those devices that can do everything they want, and it can be designed in a way to give them the experience they want.

Healthcare has almost everything it needs to recast consumerism.  The only thing missing is defining what it should look like when it’s done and someone with the will to do it.

Jump into the hole with me and we’ll figure this out.


What is the Patient Portal Fallacy?

I mentioned that I moved to Portland, Oregon. When I landed at PDX, I told my friend that the number of Republicans in Oregon had just doubled. If you’ve ever added a drop of oil to a solution of vinegar and water you may recall that the vinegar and water seemed to run away from the oil. I was Portland’s drop of oil, and no amount of shaking was going to result in a vinegarette.

Not all my meetings with health system leaders go as well as I might have hoped.  I was in the mode of part mad professor, part merry prankster. However, I tried to appear polite. I sat upright and placed my hands on my knees like I was sitting in a pew.

“You know what year it is, right? It’s the future.” I told the health system’s call center manager.

“As much as I might like to hear about the future you come from, I’ve got a hundred people on hold who want to talk to us.”

“Doesn’t that suggest that you have a problem?”

“No one knows if that’s something or nothing.”

“You should put those words on a patch for your employees to wear.  Like a motto on a scroll below two crossed question marks. Since you don’t have a CRM system if you need to call someone back, how do you find their number?” I asked her.

“We look them up in this phone book.”

“Why is the phone book on a chain?” I could tell she was getting tired of me interrogating her.

“People steal them. Don’t you remember the 70’s?”

I looked around at her call center.  “You appear to be very bright.  This is customer experience, it’s not like splitting the atom.  Judging from what I see here, this place is still waiting for the 70’s to arrive.”  Knowing that I was never going to get her to jump ahead even to the decade of faxes and pagers, and judging that my time had expired, I turned and ran for the door, lest I got swallowed up in healthcare’s version of Back to the Future, Part Deux.

So that was my day.

Many health systems believe their patient portal is a big step towards meeting the needs of consumers.  This chart should put that belief to rest.  Patient portals exclude most consumerism needs and experiences.  They exclude (RED)non-clinical needs, most of the people who have needs (non-patients), and when most of those needs occur.  And for those health systems who continue to believe that their call center is consumer friendly, the fourth pie-chart shows that the typical health system’s call center is closed three out of every four hours each week.

Patient Portal Failures

Consumerism: Fool Me Twice, Shame On Me

dogI just moved to Portland, Oregon. Nobody here has a tan. I’ve discovered twelve new species of moss. It’s the only place I’ve run where I’ve seen moss growing in the streets. I’ve been thinking of getting a dog but I’m concerned that when I let him outside that if I leave him out too long, he’ll come back green.

Consumerism Axiom: Experiences that don’t create value from the perspective of your patients will never create value for your health system.

Here’s why.

There are two types of people; those who will try something until it works, and those like me. I may try something once, but if it’s too much work, or if it doesn’t work, I won’t even consider trying it a second time.

Last weekend my wife and I did the grocery shopping. Not my favorite activity, but there I was pushing the cart.  We shop differently from one another.  I approach grocery shopping in much the same way a NASCAR pit crew approaches changing refueling and tires.

Speed counts. Efficiency counts.  Up one aisle and down the next.  Bypass the aisles I don’t need to visit.  No grazing. Not stopping to view the items highlighted by flashing red lights.  I don’t pause to taste the toothpick-skewered mini pigs-in-a-blanket offered by a maternal-looking employee.  Squeezing tomatoes to test for ripeness is forbidden.

And if someone unaware or indifferent to my need for speed, parks their grocery cart in the middle of an aisle, blocking my path, a cold sweat appears on my forehead, and my eyes are sweeping the aisle to hunt down the offender.

Anyway, back to my wife and me.  My wife does not shop the same way I do.  She’s not into NASCAR. She’s a grazer.  She approaches shopping with the notion that if the store thought an item was important enough to sell that it is probably important enough for her to view.  Grocery stores have lots of items.  I do not have lots of patience.  No sooner had we made it past the fruit and vegetable supplies the blood pressure app on my watch was sending me alarms.  While she was searching for something skewered on a toothpick to taste, I was looking around for a rest area for husbands, thinking perhaps I could watch an entire baseball game and take a nap while she grazed.

We had finished our shopping and went to pay for our groceries.  She immediately directed me to push our cart to the self-checkout aisle.  I tried to warn her off.  “Those things are a waste of time,” I told her.  (Did I mention patience was not my strong suit?)  I began to turn the cart towards a checkout line that had someone with a pulse to scan out items.  In a flash, she blocked my path and gave me the look.  You know the look—nice try, but we are doing this my way.  I demurred.  Big mistake.

There we were.  Us against the self-checkout scanner.  And then she reached into her purse and withdrew the envelope—the envelope with the coupons.  Coupons take time, and they require the patience of a saint. I was so far back in the line for canonization that it would require another two or three papal conclaves before I might hope to see the front of the line.  (Did I mention patience was not my strong suit?)

The self-checkout process failed at the scanning of the very first coupon.  She pushed the button to ask for help.  A red light flashed above our register.  The store’s hallway monitor made her way to our register, inserted her fail-safe key, and the red light stopped flashing.  The monitor began to return to her station.

I did not want to see her leave us alone and helpless.  I begged her to stay.  “We both know this is not going to go down well.  She has more coupons.  We have fruits and vegetables that do not have barcodes that can be scanned.  We are going to be here for hours,” I whined.

“If you think you are going to need that much help, you should go to one of the lines where there are checkers.”

I looked at my wife. The expression on my face was one of pleading.  The expression on her face was one I knew well—get over yourself.  At this point, I would have been calmer had I been giving myself a root canal.  Feeling like my head was about to explode, I again started to look for the rest area for husbands.  Other husbands were doing the same thing.

Two kinds of people.  People who believe processes are supposed to work and people who know processes won’t work.

Those kinds of people bring those same aspirations and prejudices to healthcare.  Some believe that if they go to their health system’s website enough times that sooner or later they will be able to do what they need to do.  That if they call the call center enough times that someone will be able to help them.

And then there is me.  You get one chance to meet my expectations, to give me the experience I want.  I am not going to beat my head against a wall hoping that things improve.  Fool me once, shame on you.  Fool me twice. Shame on me.