The woman in front of me at the checkout line in the grocery store had two full shopping carts filled to their rims with food.  She began placing her items on the belt, one item at a time, sorting them into neat categories; perishables, organic, canned goods.  I tried using my ventriloquism, repeating the phrase “get out of the line…get out of the line.”  I could see her looking around trying to place the voice, but she remained fixated on her sorting…place the frozen Salisbury steak next to the TV dinners.

A felt a bead of sweat start to trickle down between my shoulder blades and a slight shiver overtook me. I pictured her in front of me at a salad bar, inspecting individual chickpeas prior to placing them on her plate.  The only other thing that could have made the situation more untenable is if the grocer decided to play Celine Dion’s Christmas CD over the loud speakers.

After about twenty minutes the last of her items had been scanned, and the clerk announced the amount. The woman fumbled about in her purse, pulled out a large white envelope, and withdrew a fistful of coupons.  The voice in my head whispered to me “I thought we agreed there would be no killing this time.”  Ten more long minutes passed.

The store manager and I simultaneously saw her reach back into her purse.  Even before we saw it, we both knew she was reaching for her checkbook.  The manager knew he only had a couple of seconds to try to stop me from exploding.  He leapt the service counter, pushed aside the boy bagging the groceries and flung me to the floor.  A Good Samaritan in the next aisle straddled my legs while the manager hooked me up to an IV of Benadryl, and shielded my view from the woman as she was escorted from the store by security personnel.

That was my day.

If experience teaches us anything it teaches that if we represented the people who think they understand business strategy and planning on a Venn diagram, and also represented the people who actuallyunderstand business strategy and planning on the same diagram, the number of those who actually understand it would be like comparing the circumference of the donut hole to the circumference of the donut.

About one hospital in seven actually has a defined patient experience strategy, and of those that do almost all of those strategies focus exclusively on what occurs within the hospital, and almost all of them rely exclusively on improving HCAHP scores.

That said, we can make a few observations about why it is difficult for any hospital to make any significant improvements regarding patient experience:

• 85% of hospitals do not have a system-wide patient experience strategy even though ninety percent of hospital executives rank improving patient experience as their first or second priority over the next three to five years.
• Of the fifteen percent with a strategy the vast majority of those strategies are constrained by what occurs to the patient in the hospital.
• Most hospitals do not measure the experiences or levels of satisfaction of their outpatients or discharged patients.
• It is possible that no hospitals measure the experiences or levels of satisfaction of prospective patients.
• A strategy to improve HCAHP scores is not the same as an enterprise-wide strategy to improve access and patient experience

Where is the hospital’s definition of patient experience?  Where is the plan?  Where is the strategy? What is the retention goal?  The referral goal?  Everyone who tries to do business with your hospital by calling it or by going online to schedule an appointment or pay a bill has an experience. Having an experience is far different from having a remarkable experience.

While data and coaching may add a percent or two here and there, to patients and prospective patients the experience your hospital offers will appear the same a year from now as it does today.  Unless you reinvent patient access and experience, a you will never know how many people have decided to take their healthcare somewhere else.

Listening to NPR I heard the columnist from the LA Times, David Lazarus, recount the experience of his recent stay at the UCLA Medical Center, a result of his cat trying to devour him.  Fifty-two thousand dollars; four thousand a night for the room and there was no HBO—more than the cost of the Premier Suite at the Beverly Hills Hotel.  Remember this little fact about the room; we will come back to it.

For any given patient, the highest that patient’s satisfaction will ever be is the moment the patient exits the hospital.  The likelihood of increasing patient satisfaction after a person leaves the hospital is no better than the chance of counting backwards from infinity…twice.

What happens, you see, is that while the patient is in the hospital the hospital believes it exercises some sort of control over the experience relationship.  Perhaps this is where the notion of patient experience management originated. 

Patient experience and patient satisfaction are always being managed.  Sometimes the management of the patient is proactive and deliberate, other times it is managed neglectfully or inadvertently.  Rarely has the experience been designed; most times it has simply evolved.  Just because the experience is being managed does not mean the outcomes will be favorable.  Unfortunately, this surprises some executives.  Perhaps this should be a ‘predictable surprise’.  When the patient is discharged nobody is managing the patient’s experience.

What if patient satisfaction and patient experience could be managed effectively for all patients and across all touchpoints, not just when they are inpatients?  Assuming healthcare was a business, what if patients were treated by hospitals as assets—assets valued at between $180,000-$250,000—patient equity management (PEM)?  Business is not a four-letter word in healthcare.  Hospitals market to attract patients.  Why not have programs to increase patient equity management, to retain patients and their families over their lifetime? 

Why not institute a program of family experience management, family equity management?

Why is nobody managing the experiences of people who call the hospital, and people who visit the hospital online?

There are a handful of major business processes each patient encounters, processes like admissions, scheduling, meals, billing, and claims.  Each of these processes impact a patient’s experience and satisfaction.

Let us jump back to the point about the four-thousand dollar room, not the charge itself, rather the room.  A hospital’s nonclinical business processes can be mapped almost one-to-one to those of large hotel.  One difference one finds when comparing the business processes of a hospital to a hotel is that the satisfaction levels as measured against those processes of the hotel will almost always be higher.

When patients use social media to comment on their stay at a hospital, these are the processes on which they comment.  Patients rarely complain about the doctor replacing the wrong hip.  They do however complain about not being able to schedule an appointment or about not being able to understand their bill.  Hospitals have no weapons with which to defend themselves against the electronic 1’s and 0’s of poor satisfaction; the internet is forever.  The hospital’s only defense against poor satisfaction is to improve the patient experience.  To improve the experience a hospital must learn which touchpoints help define someone’s experience, and then they must design the experience.

Mr. Lazarus from the LA Times met with the president of the UCLA Medical Center to discuss his bill.  The president told him that not only did he not understand Mr. Lazarus’ bill, he did not even understand his own bill.  Mr. Lazarus reported that in his article and on NPR.  The circulation of the LA Times is slightly above a million.  No amount of effort is going to put that toothpaste back into that tube.

Some, who feel their way along in near-perfect darkness, have what might be described as the fatally limited hypothesis that there is not much to be gained by improving nonclinical processes.  The individual with a single hypothesis about how to improve matters feels more comfortable with the status quo. 

These same people believe that they have patients, not customers.  People who think that way may soon have neither.

Sometimes we know things intrinsically; we do not need someone to spell it out for us. That said, the message on sign on the wall of the reptile house at the Philadelphia Zoo was “More than fifty percent of the people killed from snake bites are males below the age of 30 who tried to handle a snake.”

Sometimes something gets stuck in my head and the only way to get it unstuck is to get the idea stuck in someone else’s head.  A few weeks ago I came across something on television having to do with a Canadian paleontologist sitting on a pebbled beach in Quebec.  He came across as the type of individual whose interest in science may have come from his belief that perhaps the Flintstones television show was really a documentary.

The paleontologist work revolved around discovering the place where fish first walked from the sea—the very fact that he was interested in finding out where they first walked seems to imply that they (fish) have walked on more than one occasion.

I know some of you are thinking, ‘And your point in writing to us about this is…”.

The television spot went on with the fellow concluding that the interesting thing is not that fish walked—which I would have found sufficiently interesting—epochs later; yada yada yada—but that without them having walked none of us would be here.  It was alchemy in paleontology and the television reporter, a willing dupe, was his Rapunzel.

What troubles me about this is that he and his amanuensis, the reporter, with her eyes wide shut, somehow managed to create a dialogue around this notion as though it (the meaning of life) actually happened the way this fellow said it did.  Her interview was like watching two left-handed men learning to dance backward without either one knowing the woman’s part.

The voices in my head started screaming epitaphs at me.  The paleontologist’s mind tacked intuitively and lurched from idea to idea untouched by the clammy hand of logic.  His premise made as much sense to me as having an oboe player in a punk rock band, yet the erstwhile reporter, with her sang-froid composure, uttered nothing more than ‘uh-huh’. It looked as though she was watching time bend as he explained the wonders of the universe to her with his do-re-mi recitation of the facts.

Some people in front of a camera have the innate ability to insult our intelligence with boredom and futility.  To me his perfervid idea seemed stranded on the edge of reality and worked about as well as a poorly used preposition at the end of a sentence.  The reporter listened and nodded and stared into the looking glass.  She never questioned whether the compass of the fish-walker’s intellectual qualifications may have been missing its needle.

Therein lays the rub.  Simply saying something aphoristically on television does not make it true.  What was intended as an ephemeral interview now exists for the folly of all of us.  The man is guilty of sharing his ideas without having a hall pass to do so, but then again, we have all done that at one point or another.

Sometimes our confusion comes from a lack of specificity about the topic being discussed. I think patient access and patient engagement could be one of those topics.  I think part of the confusion is that the two terms, patient access and patient engagement, have meanings that differ depending on the makeup of the people having the discussion.

Most people think of patient access in terms of people having access to healthcare, in terms of healthcare being available to them.  Likewise, people often think of patient engagement as engaging patients while they are being treated.

I look at healthcare as having two facets—the healthcare business (the services provided), and the business of healthcare (running the business). Looked at a slightly different way, people need two things of their provider; they need to get better, and they need to be able to do business with their provider.

Access and engagement each play a role within both facets.  As a patient I need access to healthcare—my doctor, a clinic, a hospital, but I also need to be able to access my provider in order to perform certain business processes.  Those processes include things like registration, scheduling, authorization, insurance verification, admissions, billing and collections, and disputes and claims. 

In most hospitals that type of access is limited to using the telephone or in having to enter the hospital to complete one or more of those processes. Efficient? No. Effective? Not very likely. If a person has more than one need, they either have to meet with multiple people in multiple departments. Or, they have to speak to multiple people on the phone, being placed on hold, having their call transferred, and having to call back more than once.

In most hospitals access and engagement are on a one-way path, from the hospital to the patient. Hospitals use CRM systems as a business development and marketing tool; the hospital calls the patient.  EHR, set up by the hospital, allows patients to read about themselves.  The hospital’s website allows people to read about the hospital.

These tools do not enable access and they do not facilitate engagement.

They should.

Creating two-way access would benefit the hospital five ways:

• Increased retention
• Increased referrals
• Decrease back office support costs
• Reduce readmissions
• Improve population health management

So, where does that leave us with the guy looking for the walking fish? Maybe that is how mermaids came to be.

There are three people in the ER. One of them is a physician, one of them is an executive, and one of them is a consultant. They see a machine unplugged that is standing against a wall in the waiting room.

And the executive says, ‘Look, the technology in this hospital is not used.’ And the physician says, ‘No. There are machines in the hospital of which at least one is not used.’

And the consultant stood there in silence guessing neither of them really cared what he thought about the machine.

At least one. A mathematical term meaning one or more.

Some. A non mathematical term.

The term is commonly used in situations where existence can be established but it is not known how to determine the total number of solutions.  In our example, ‘E’ represents the unused machine and ‘C’ represents the unused consultant—the exceptionally bright among us will notice there is no ‘C’.  That is a problem on my end, but I digress.

How many things can be changed regarding the patient access that would have a positive impact? At least one.

What would you change if you were not afraid of failing?

My phone had ceased to function as a phone and so I was at the Verizon store with little to do.  I was counting backwards from infinity, twice, and I got stuck when I got to the number fifteen; I hate when that happens. 

I think originally what I encountered at Verizon may have happened like this.  One of Verizon’s mail clerks, Ferguson, wanted to change his phone to the iPhone. He went to the Verizon store and learned he could trade in his old phone for a shiny white iPhone and receive a thirty dollar refund for doing so provided that he signed a two-year contract.  Deal done.

Ferguson went back to work in the mail room, and since nobody actually mailed letters and packages anymore because the world had gone digital, he started to think.  He knew he was going to get the iPhone, and a $30 refund had no influence over that decision.  He thought others would have acted accordingly and would have upgraded to a new phone even without the rebate.

Using his Jot Stylus on his iPad, he channeled Jethro Bodine and commenced to ciphering.  Roughly one hundred million mobile customers.  Figure twenty-five percent of them upgrade their phones each year.  Ferguson estimated the refunds cost Verizon seven hundred and fifty million dollars a year.  Now Ferguson guessed that those customers, if for no other reason than the panache factor of having the newest, coolest phone, would have upgraded even without a rebate.

Ferguson’s hamster wheel started spinning and he wondered if the desire to have a new phone was so strong that customers would still upgrade their phones even if Verizon charged a thirty dollar upgrade fee instead of offering a thirty dollar rebate.

Ferguson gets an idea.  He scribbles out a postcard on the back of his rebate card, addresses it to Verizon’s CEO, and hand-delivers it to him on the executive bocche ball court.  The postcard posits Ferguson’s idea as follows; If we charged customers the same amount to upgrade instead of rebating them, we could swing revenues by one and a half billion dollars.

Ferguson is now the Executive Vice President of Innovation & The Heck With Customer Experience.

Nota bene, I paid the thirty dollars.

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 interactions clinical interactions and on things having to do with HCAHPs.

Every day many more patients and prospective patients try to access (interact) with the hospital using the internet and their phones. Much determination on patient satisfaction is made in these venues. 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, on any device.”

To move towards the goal of being remarkable, one must talk to patients and observe them in those access points 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 most of the people in your radius of influence; for all of the prospective patients and nothing for former patients whose next visit to the hospital you never learn of because it happened somewhere else.

The level of satisfaction for these individuals is determined outside of the hospital’s four walls.  There are gobs—a consulting term of art—who never decide to become patients or to become patients again that make their decisions based on a hospital’s internet presence and how their calls are handled.  HCAHP surveys will not entice people to become your patients.  There is not a prospective patient in the entire country who knows a hospital’s HCAHPS score or what that score means.

These people belong to a group called the unsurveyable.   They also represent a healthcare spend higher than your total revenues for last year.  Why not pay attention to their experience?

Some of you may be old enough to remember when cars had hubcaps. Shiny metal things that made your wheels look nicer.  Shaped like a Frisbee; round, convex, and designed to fly. Today, cars do not have hubcaps. I think that is because when your car hit something the hubcaps tended to leave the wheel at a speed of Mach 2 and impact whatever they hit with the force of a cleaver.

If you were riding in your car, you did not know if your hubcaps were on the car, or if they took flight when you hit the last pothole.  You didn’t know because you could not see them from your position.

Last week the woman next to me complimented me on my cufflinks.  I had to turn my shirt sleeve around to see which ones I was wearing.  Cufflinks are a lot like hubcaps in that way—you cannot see them unless you make an effort.

Patient access is a lot like hubcaps and cufflinks.  From where most hospital executives sit they cannot see patient access or patient trying to access their hospital.  To see whether access works, to assess its effectiveness one must go and observe it.  Observe what happens when a patient calls the hospital to accomplish a task. Observe what happens when a patient tries to accomplish something online.

From what I have observed, if hospital executives actually looked at access they would either find it to be broken or at least in need of a makeover.

If you haven’t made over access since people started conducting their business on smart phones and tablets your access is not what it needs to be. And if I cannot access you, it does not matter to me how noisy your hospital is or how communicative your clinicians are. I will keep calling hospitals until I find one that thinks my call is important to them.