Nine miles into my run I was at the apex of the bridge crossing the bay, leaning over the guardrail to catch my breath. To my surprise, a state policeman pulled alongside of me.

“What are you doing?”  He asked, a tone of concern in his voice.

Since I was trying to cross the bridge, I thought about asking him if his question was like why did the chicken cross the road, but he did not look like a chicken crossing the road kind of guy.

“Are you okay? You don’t look okay.”

“I’m fine. Why did you pull over?” I asked.

“We got some calls about a guy on the bridge who looked depressed. Are you thinking of jumping?”

“Jumping what?”

“Jumping off the bridge. Are you sure you are okay? You look depressed.”

“I think I look like I just ran nine miles.” I placed my foot on the guardrail to stretch my hamstring.

“Take your foot off the bridge,” he commanded. “I was about to call for a helicopter. Are you sure you are okay?”

I was going to ask him if the helicopter would give me a ride back to our house in Ocean City, but he didn’t look like a give me a ride back kind of guy. “May I continue across?”

“No, you can’t do that here.”

An interesting statement, You can’t do that here. I was looking at a hospital’s website and there was a link suggesting if I clicked it I would be able to schedule an appointment.

I clicked it. The next page told me how good the hospital was. The page after that told me about all of the services they provided. The last page told me that if I wanted to schedule an appointment that I should call the hospital Monday through Friday between eight AM and five PM.

The website’s page should have included 24-point bold disclaimer stating, You can’t do that here.

Sort of like when I was trying to cross the bridge.

Most hospital websites should offer that disclaimer, You Can’t Do That Here. On most hospital websites people cannot do anything except read about the hospital. People are looking for an easy way to do business with their hospital, a way that has a great user experience.

Maybe you should turn your hospital’s website from a brochure into a business tool.

Does the fact that there are so many different definitions of patient experience among hospitals belie that fact that there is no definition of patient experience? 

Most patient experience definitions seem to be missing a few things; they do not exist much beyond the four walls of the hospital—sort of like EHR, they are highly, if not exclusively, focused on things having to do with HCAHPs.

(If you want a downloadable presentation on the questions not covered by HCAHPS, you can get it at: The Experiences HCAHPS Doesn’t Survey)

Every day many more patients and prospective patients interact with the hospital using the internet and their phones. Much determination on patient satisfaction, by patients, is made using these tools. Retention, referrals, and ‘win-backs’ are influenced here. “Buying” decisions are made and lost here.  The hospital either met or did not meet expectations.

Yet most hospitals invest almost nothing in the two areas that have the highest number of touchpoints.

If I were asked to define a goal for patient experience I would recommends “A remarkable experience for every patient every time, obtainable on any device, at any time, at any facility.”

To move towards the goal of being remarkable, one must talk to patients and observe them in those touchpoints that all patients use. Surveying patients puts out the fire, it does not prevent fires.  Their bad experience has already happened. 

Surveying patients, paying for patient experience data, and paying for coaching does nothing of value for most of the people in the hospital’s radius of influence. It does nothing for all of the prospective patients and nothing for former patients whose next visit to the hospital is never recorded because that patient went somewhere else.

The level of satisfaction for these individuals is determined outside of the hospital’s four walls.  Writing a million dollar check to have a firm coach your employees does nothing.  There are gobs of people—a consulting term of art—who never become patients or never become patients again. These people make their decisions based on their online experiences with the hospital and on how their calls to the hospital are handled.  HCAHP surveys will not entice them to become your patients.

There is not a patient in the country who can tell you the HCAHPS score of any given hospital.

These people whose experiences are unknown belong to a group called the unsurveyable.   They also represent a healthcare spend higher than the hospital’s total revenues for last year.  Why not pay attention to their experience?

My twelve-year-old son commented as I was ready to depart for my run. “Are you really going to wear those shorts?”

“What is wrong with my shorts?” I asked.

“People want to see a lot less leg and a lot more shorts,” he replied.

“How long do my shorts need to be?” I asked. He pointed to a spot between my knees and ankles—capri-length.

If I wore something of that length in red or blue in most major cities in the US I might be mistaken for a gang-banger. Except for the briefcase, the ultra-notebook, and my tan Allen Edmonds wingtips.

That is what got me thinking about forming a management consulting gang, marauding through C-suites wearing white, highly-starched, Egyptian-cotton, below the knee shorts with the Allen Edmonds wingtips—hair gel and manicures are optional.

You probably know that the half-life of something is the time required for a quantity to fall to half of its measured value from what it was at the beginning of the time period.  Its most commonly used with exponential decay, like measuring the age of rocks based on the decay period of radium to lead-206.

The satisfaction with one’s patient experience is the inverse of half-life.  The level of satisfaction of the experience does not diminish over time, it actually grows, and with social media it grows unbounded, at least the bad experiences do—sort of like telling your friend how large the fish was you caught; over time the size of the fish gets bigger.  A story of an unsatisfactory or a bad patient experience has legs, and patients who had a poor experience do their utmost to get their story to the most readers.

A friend of mine who reads this blog called me to relay her story. She is being treated for cancer at a major institution in Baltimore—I’ll leave it to you to figure out which hospital.  She tried to make an appointment to see her doctor because of the side-effects from her anti-nausea medicines.  She said she spent three hours on the phone trying to schedule the appointment.  While she acknowledged that the hospital was the best place for her to be treated she stated that she was going to make it her mission in life to tell people not to go to that hospital simply because they could not handle a simple business process like scheduling an appointment.

Think about the most inane stories someone ever told you.  People, guy people in particular, have a tendency to exaggerate and to add a flourishes that grow over time.  The bad news for healthcare providers is that once patients’ stories hit the web they multiply.

If you want to know how others view your hospital, much more information can be learned from Google than from CMS.  And the opinions on Google, whether accurate or exaggerated have no half-life, that genie is not going back in the bottle.

Hence, the only influence you have over someone’s experience is while they are having the experience.  Once they’ve had it your chance to manage it is over.  And the thing that should concern hospital executives the most is that they do not even know that people are having these bad experiences.

These experiences are not learned from a Ouija-board secret-shopper exercise.

Ninety-percent of the experiences people have regarding their interactions with a hospital are unknown to the hospital, unmeasured by the hospital, and unreported. Companies like Amazon track the successfulness of each interaction of each person.

I watched the movie Jaws recently. It was made in 1975. In 1975 I looked like the keyboard player for the Moody Blues (see photo). I wonder how different the movie Jaws would be if someone tried to make it today using today’s technology.

Bathers would see the shark’s fin. Using Bluetooth, they would triangulate on the fin, send a GPS signal to any CIA drone not targeted on some Middle-East Sadam-wanna-be. The drone would shoot a Hellfire missile into the surf on Amity Island, and the tourists would be dining on sushi.  Game over. Movie over. Pass the wasabi and pickled ginger.

When Jaws was filmed in 1975—where is Richard Nixon when you need him—if any of the visitors to Amity Island fell ill, there was no way for them to go to the Amity Island Hospital’s website to check their symptoms. No way for them to schedule an appointment online. No way for them to request a refill online. No way to seek a second opinion online. No way to call from the beach to talk to a nurse.

Technology is great, unless you have spent the last forty years without it, or you are looking to upgrade to a newer version of your Palm Pilot. In the movie Father of the Bride the wedding planner Franc (Martin Short) responds to Steve Martin saying “Welcome to the 90’s Mr. Banks.”  Sometimes it seems like the business of healthcare, how healthcare is run, has yet to be introduced to the nineties.

Thirty-nine years have passed since Jaws was released. If you happen to be one who studies the business of healthcare it would appear that not much has changed except for the fact that hospital administrators no longer wear bellbottoms, platform shoes, and puka-shell necklaces, and they no longer sport moustaches and long sideburns and long hair.

Accessing a healthcare institution remains the way it was in 1975.  For the most part it cannot be accessed it online. You can barely access it by phone. You still are not a customer or a potential customer.

Many hospitals still believe they have patients, not customers. Unless they change that perception the time will come when they have neither.

There are two ways of looking at access; access to the organization and access to healthcare. 

Healthcare is very impressive. At a recent meeting of the Cardiovascular Leadership Institute Leadership Council of Penn Medicine we watched of video of the transformation of a skin cell into a heart muscle cell—it began to beat!  We can treat numerous cancers and can transplant a face.

We can do everything except schedule an appointment. It may be time to trade in the Palm Pilot.

US soccer fans are a lot like locusts. However, instead of surfacing every seventeen years, we surface every four. Once we are out of the Cup, we are really OUT. Four years ago we will once again try to understand the relevancy of the “offside” rule, and wonder why FIFA does not increase the size of the net and use more than one ball at a time. To badly paraphrase Shakespeare, “We are now in the summer of our discontent,”—the doldrums of professional sports. Pro hoops and hockey, which most people do not equate with sports worth watching have concluded their seven month playoff run, baseball’s 162 games are hitting their midpoint, and football is just a dream on the horizon.

Maybe now American’s can get back to some of the other global sports televised on ESPN channels 31-57, like darts and lumberjacking.

Have you ever wondered why hardware stores sell drills? The next time you are at Home Depot, tell the clerk you need a two-inch hole, and ask the clerk to direct you to the aisle that sells the holes. Stores sell drills because they do not sell holes.
In keeping with the hardware theme, in my workshop I reached for one of my hammers. Have you noticed that hammers survived evolution intact? The one reason hammers haven’t changed is simple—nails have not changed. Long handle, heavy piece of metal at one end. All you need, and nothing you don’t.

The collective noun ‘patient experience’, as viewed by most of the healthcare industry, is no more evolved than a hammer. Thirty-two questions seeking thirty-two answers.
However, patient experience is made up of the individual experiences of thousands of individuals—small things. Small things, which when combined become one very big thing. HCAHPS is the repository by which hospitals have tried to herd the collective experiences of the people in their service area. The problem is that people are no easier to herd than cats.

For HCAHPS answers to be of any use they require the gift of hindsight. It would be better if hindsight was available ahead of time.

Hospitals have a tendency to treat HCAHPS scores like pieces of a large patient experience jigsaw puzzle. Unfortunately, nobody has seen the picture on the front of the puzzle box. Assuming patient experience can be improved just by trying to increase HCAHPS scores makes the solution seem artificially easy, like hoping the nail you are about to hammer isn’t a screw. HCAHPS has a finite number of questions, and a finite number of things to be fixed. But in truth, fixing the problem with patient experience is more like counting votes in Florida.

Problems fall into two boxes; easy and difficult. An easy problem to solve is “Do you want fries with your order.”  A more complex problem, one I faced two weeks ago was helping my daughter buy a dress for the eighth-grade dance. I have some experience buying clothes, and some experience going to dances, and even some experience buying clothes to wear to dances. My eighth-grade dance outfit included bell-bottoms, a puka-shell necklace, platform shoes, and long hair. Ergo, I felt reasonably well-equipped to guide my daughter.  She did not share my confidence, nor did she choose any of the dresses I recommended.

What if most difficult problems were not so difficult? It is easier to get our arms around difficult problems. We know how to acquit ourselves to suss out solutions. We have meetings, someone drafts and agenda, somebody else brings the bagels. We employ subject matter experts—people with PhDs and MDs.  Hire a few consultants. People join the meeting using Facetime, others take notes on their iPads.

That is how we handle difficult problems. That is also how we handle problems that we assume are difficult even if it turns out that the problems are not difficult. For the next three minutes, let us agree to lay aside the oracles of our profession and consider if reducing readmissions and facilitating population health management should be moved from the difficult column to the easy column.

If you choose to continue reading, some of you will conclude that Paul is having a stupidity, and others, hopefully, will conclude that Paul may have had an epiphany.

Washington University in St. Louis reports that twenty percent of patients are readmitted within thirty days of discharge.  Modern Medicine reports that twenty-five percent of patients are readmitted within two years.

Kaiser Health News reported that readmission rates are not budging.  According to AHANews.com, readmission rates for 2012 dropped from an average of 19% from 2006-2011 to 18.4%–perhaps a budge.  Budging or not, it appears that in spite of all of the emphasis and all of the efforts to decrease readmissions, the rate of readmissions remains relatively static.

If the current efforts are not working, what if we tried something else?

Please pay particular attention to the wording of these two Top 5 lists.  The first list seems to lay the blame for readmissions squarely on the patients.  The second list, my list, suggests there is plenty of blame to go around, and could equally be parsed to include hospitals.

I will argue in a second that the ownership of the blame is irrelevant, and that the solution is neither patient-centric nor hospital-centric—it is both. I will also argue that the solution could easily decrease readmissions by double-digits.  But please don’t throw metaphorical tomatoes at your monitor without understanding the entire argument.

The Top 5 reasons for patient readmissions according to the Dartmouth study, Care About Your Care are:

• Patients may not fully understanding what’s wrong with them
• Patients may be confused over which medications to take and when
• Hospitals don’t provide patients or doctors with important information or test results
• Patients do not schedule a follow up appointment with their doctor
• Family members lack proper knowledge to provide adequate care

Written a little differently—my way:

• The hospital does not ensure that patients understood what’s wrong with them
• The hospital does not ensure that the patients understood which medications to take and when
• The hospital does not provide patients or doctors with important information or test results
• The hospital does not ensure that patients scheduled a follow up appointment with their doctor
• The hospital does not ensure that family members had the proper knowledge to provide adequate care

What observations can be made and what conclusions should be drawn from the above information?

According to the Top 5 list patients and their families lack the information that would keep them out of the hospital.  And who has the information that the patients and their families lack?  Say it with me, the hospitals.

So, what do we need to reduce readmissions? The patients need information from the hospitals.  And, here it comes, the hospitals need information from the discharged patients.

Let’s look at two patients, both with very similar issues who were discharged. The first patient goes home with their discharge orders and receives a call from the hospital asking how they are doing.  The second patient goes home and is watched daily, and their health is assessed daily. Which of the two patients is most likely not to be readmitted?

While the answer is obvious, we all know that if a patient is going to be watched and assessed the entire time they are away from the hospital that they may as well remain in the hospital. Unless. What if there was another way to implement that approach?

Let’s begin with the notion that hospitals need a way to ensure that patients and their families have all the information they may need, and that patients ensure that the hospitals have timely (hourly and daily) access to all the information they may need about their condition.

What information is needed by the hospital to lay the foundation for a viable solution?

• The hospital needs access to the right patient information to assess a turn in the patient’s condition.
• The hospital needs to assess the patient’s information early enough to prevent the need for the patient to be readmitted or to go to ED.
• The hospital needs to be able to use that information to know when to contact the patient and to know what to do to prevent the patient’s conditioning from worsening.
• The hospital needs to provide care to the patient that prevents the patient from needing to be readmitted or prevents the patient from going to ED.

What is needed by both the hospital and its patients?

• A timely and accurate way for patients to tell the hospital what the hospital needs to know
• A timely and accurate way for the hospital to tell the patient what the patient needs to know
• A way for both parties to assess the information
• A way of knowing how and when to communicate that either party’s information requires action.

What do they need, when do they need it, and how do we make it happen? Instead of hospitals wishing they had access to real-time information about their discharged patients, and patients wishing they had real-time access to more information about their status, why not make that information available?

What if, prior to discharging a patient, the hospital added the patient to the hospital’s “Discharged Patient Portal?”  The hospital may even provide the patient with a smart-device, with a killer user-interface, to allow the patient to get all of the information the patient needs, AND, to provide the hospital with all of the information the hospitals needs about the patient.

Our cars can do this. They can tell us, based on the data they collect, when we need to see a mechanic. Why can’t we create the same interaction between discharged patients and their hospital?

I have enough everyday stress to keep me happy without having someone manufacture it for me. It’s not like I have anything against flying; I just have something about other people flying with me. My wife would argue that I have the same issues with driving. (She and I tend to work similar schedules but we don’t always arrive at the same place at the same time. Sometimes one of us takes too long to put on their makeup, and the other one gets impatient and leaves.) When I think about it I am at my best when I am locked in a room. There I have the luxury of talking to myself with the knowledge that I am talking to an intelligent person.

On this flight I am seated next to the plane’s water closet. The queue my fellow travelers formed in the aisle made me wonder if someone had discovered gold in the WC. The person closest to me was doing the “I need to go sooner rather than later dance,” and her motions made her look like a bear undergoing electro-shock therapy.  Naturally, the queue began to bother me, so I began to charge each person a toll to get by.  The flight attendant informed me that if I continued this behavior that I could kiss my bag of peanuts goodbye and that I would be sent to the US AIR re-education camp to atone for my sins.

Apparently Gilligan had just gotten off the island, and on this flight he was seated across the aisle from me. He snacked on something that looked like trail-mix, but I couldn’t tell what trail it came from. I, on the other hand was eating a croissant from Paris. I tried to convince him that if he held it to his ear that he could hear the sounds of a sidewalk café. He dressed with all of the fashion sense of an accordionist in a Wisconsin polka band. The look in his eyes suggested that he might be the type of person to walk into a Seven-Eleven and take down everyone because the Slurpee machine wasn’t working. 

One summer I was offered a job drawing caricatures in Ocean City, Maryland. I longed for my pad of paper as I scanned my fellow passengers many of whom looked like they had been plucked from the bar room scene in the Star Wars Cantina.

Enough about my day.

In 1958 a group of MIT seniors went about measuring the Mass. Avenue Bridge.  They didn’t have a ruler, but they had Smoot, Oliver Smoot.  The seniors made marks along the bridge, one for every smoot.  The length of the bridge is 386 smoots plus one ear.  Ever since that day, each time the bridge is repainted, the Smoot marks are repainted to ensure they will be around for future generations.

Healthcare seems to enjoy measuring, perhaps because the folks in Washington seem to like reading measurements.  Maybe the time has come to start to think about the cost of all of the things that are not measured.  After all, what are the chances that the people in DC hold the patent on what does and does not need measuring?

Here are a nine examples of what we do not measure that would tell us what people really think about their access experience:

• The number of people who call the hospital whose calls are transferred because the person with whom they were speaking could not answer their question
• The number of people who hung up because they grew tired of being on hold
• The number of people who had to call time and time again to try to get an answer to their question
• The number of people who were not able to schedule an appointment
• The number of people who were not able to schedule an appointment in the timeframe they needed
• The number of people who called another hospital to get an earlier appointment
• The number of people who asked to speak to a nurse who were given a voice-mail saying that a nurse would get back to them within 48 hours.
• The number of people who upon getting that voice-mail went to the emergency department

I was about halfway through my run and had just strained my hamstring running up a long hill so I began walking. A few minutes later I was greeted with a perky “Good morning!”

I turned my head just in time to see a buoyant, twenty-something running and pushing a double pram up the hill. “That’s not fair,” I replied, and she laughed.

I wanted to tell her that when I was her age I held a world-record for a twenty-four hour run. I wanted to do a lot of things, but the only noise coming from my lips was a death-rattle. I considered my options and the only one that had any chance of restoring my dignity was to take her out, and to take her out hard. After applying the foot brake to the stroller—I had nothing against her children, I hip-checked her into the culvert. I hip-checked her so hard that I almost swallowed my dentures, knocked out my hearing aid, and dislocated my artificial hip.

“Good morning,” I told her as I began to limp away.

Segue.

Sometimes you need to take the initiative, and sometimes you need to look at a problem from a different perspective.  Take a look at the following problem.

                             XI + I = X

The numbers are written in Roman numerals using match sticks or toothpicks.  The problem is for you to determine the least number of toothpicks you can move to make the equation true.

Most people will probably think that the correct solution is to remove one toothpick from the plus sign which yields the following equation:

                             XI – I = X

Most people would be wrong.  The correct answer is that the least number of toothpicks that can be moved to make the equation correct is none.  The only thing you need to do to arrive at this answer is to change your perspective. Place your left hand on the left side of your screen, and your right hand on the right side, and turn your screen upside down. Now the equation reads:

                             X = I + IX

What if every business problem was that easy to solve?  Some of them are.  I think improving patient access and patient experience is one of those problems. Five thousand hospitals are trying to improve patient experience, and all five thousand of them are approaching the problem in more or less the same way.  That approach only focuses on the experiences of a percentage of inpatients, experience that they encounter inside the hospital and that are related to HCAHPS.

That approach requires people to believe that either nobody has any experiences outside of the hospital, or that those experiences do not matter.  That approach requires people to believe that either outpatients, discharged patients, or prospective patients do not have any experiences outside of the hospital, or that those experiences do not matter.

That approach is wrong.  That approach ignores the experiences of most of a hospital’s stakeholders.  That approach ignores where the majority of people have experiences with the hospital—on the phone and on the web.

If most people experience the hospital every day on the phone and on the web, shouldn’t hospitals make a very deliberate effort to design those experiences?  If the number of outpatients and discharged patients and prospective patients greatly exceeds the number of surveyed inpatients, shouldn’t hospitals make a very deliberate effort to design those experiences?