Can people do business with your hospital and why is that important? It seems these questions are easy enough question to answer, but how do you know the answers if you have never watched people trying to do business with your hospital?

Permit me to offer an illustration.  I dropped my phone and shattered the screen, broke the touchpad and the LCD.

He was my plan of attack. I called Verizon, my provider.  Verizon values customers at between five thousand and ten thousand dollars depending on the total number of services each subscriber has.  Figuring I was valuable to them, it occurred to me that they would want to help me find a solution for my broken phone.  I was wrong.

The Verizon representative at the store told me that since I did not have an upgrade available to me until mid-March that my only option was to purchase a new phone at the retail price.  Verizon would not waive the intervening three weeks.

I then checked with a place that repairs phones.  They could fix my phone for two hundred dollars.

I then checked with T-Mobile.  In less than an hour I had a new Samsung Note, and had unlimited talk, text, and data for eighty dollars a month—Verizon did not offer an unlimited plan.  An unlimited plan with T-Mobile will cost me less than what I was paying for a limited plan with Verizon.  T-Mobile did not require me to sign a contract.  If fact, they even paid the penalty Verizon charged for cancelling my agreement.

Two companies, supposedly in the same business, different results.

T-Mobile wanted my business, and they made it easy for me to do business with them

Which company most resembles how easy it is for people who try to do business with your hospital?  How do you know?  If you are a hospital executive, have you watched someone try to schedule an appointment or a lab? Have you listened to them on a call?  You did not watch them trying to do it from your hospital’s website because they cannot schedule an appointment from the website.

Have you watched them trying to provide your hospital with a referral, trying to pre-admit themselves, trying to order their medical records, trying to learn how to submit a claim or to understand their bill?  Only by observing people trying to do business with your hospital will you understand their frustrations.  You see, people need two things from your hospital; they need care, and they need to be able to do business with you in an effective and efficient manner.

These people, patients/customers, have a value over twenty-five years of somewhere between one hundred and eighty thousand dollars and two hundred and fifty thousand dollars.  If you are not easy for them to do business with they will make it their mission in life to find a hospital that is.

A couple of thoughts paraphrased from Gandhi.

Patients do not depend on us—they have choices.

Patients are not an interruption when they call.

Patients are not an outsider to our business—they are our business.

We are not doing patients a favor—they are doing us a favor by choosing to interact with us.

We spend millions of dollars trying to attract patients.

Why not spend a few dollars trying to retain patients and to make it easy for them to do business with us?

If you don’t, somebody else will.

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

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

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

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

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

Four rules worth remembering:

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

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

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

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

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

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

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

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

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

It is a three-dog-night, and I only have two dogs.

See Paul. See Paul shiver.  We lost power 16 hours ago—ice storm, trees snapping like match sticks and landing on the power lines. The temperature in the house is fifty-one degrees and is dropping faster than my lack of affection for all things Celine Dion.  Rumor has it that we may get power back Saturday-seventy-two hours from now.  By then I should be able to just leave the refrigerator door open without worrying about the food getting too warm.   Having lived in Colorado for twelve years, I’m pulling out all of my North Face gear; crampons, gators and ice ax just in case I need to rappel down to the first floor in the morning to let the dogs out.

Southeast Pennsylvania is having a mini version of Hurricane Katrina, only nobody is being rescued by helicopter since the roofs are too slippery to climb upon.  I am writing by candlelight, like Abe Lincoln must have done, only minus the beard and the stovepipe hat.

The cell phone charge shows twenty-two percent power left.  The iPad is dead, and the gerbils powering my laptop have taken their mandatory union break.  Alferd Packer, turned to cannibalism in Colorado when he and his friends ran out of food in the cold.  I look at my dogs. They look back at me with suspicion.

Time passes.  It is forty-seven degrees—inside the house.

Several of you have written asking what it means to design someone’s experience—you can call them a patient if it makes you feel better.  I like also calling them customers—they can be both, and it does not offend them.  Maybe we should make it like the word brunch—patomers or catients.

Anyway, customer design.  He are real examples from my personal experience yesterday of firms who did not design a customer experience, firms who designed one but did it poorly, and one firm who got it right.

There are 150,000 homes in my county without power, and every person from every one of those homes made it their mission yesterday to find power at a place that also had internet. (I’m becoming a bigger Al Gore fan every day.)  I first tried the library.  There is a big sign to let people know they have free internet.  Their lights were on, but they were closed because of the weather.  Good intent, poor execution.

I next tried the mall—400,000 square feet.  Banners hanging overhead hawking their free internet service.  I walked the entire mall.  There is not a single accessible power outlet anywhere in the mall.  Good intent, poor design.

Giant Foods is a mile from my home.  A few cars were in their parking lot.  ACME Foods is another mile down the road, another clump of cars in their parking lot.  Wegman’s—my favorite food store on the planet is another three miles down the road.  Their parking lot was packed.

If you have never been to a Wegman’s, all of their stores were purposefully designed to create a great experience.  They have an eating area with eighty or so tables and a few couches and free internet.  And they have lots of electrical outlets.

My family and I went in and I went to work.  We spent six hours there and about a hundred dollars to eat two meals.  I would have done my grocery shopping but realized it would be silly to buy food if the temperature in my refrigerator was bordering on tropical.

Giant, ACME, and Wegmans.  At first glance, one would think the three companies are in the same business—groceries.  What I learned is that two of them are in the grocery business—Giant and ACME, the stores with the empty parking lots—and the third, Wegmans, is in the people experience business.

The point is that unless your hospital has defined the type of experience it wants people to have when they visit your hospital online or call it the experience you are providing those people is probably poor.

Too many hospitals think that because they have a web site and because someone is answering their phones entitles them to check the box indicating “mission complete.”  Your customers and patients are checking their boxes too.  They come away from their experience saying it was pointless to go online because they could not do anything once they got to your web site.  They are saying it was pointless to call the hospital because they never accomplish what they set out to do when they called.

The result of an undersigned experience is a failed experience.

The result of too many failed experiences is that the person will go somewhere else to purchase their healthcare.

One final kudos for Wegmans. I found a vegetable that I hadn’t seen since I worked in Taiwan—yu choy.  I Googled it, went to Wegmans’ web site and searched for it.  Wegmans’ web site asks you to enter your zip code.  When you hit enter they site tells you in which aisle in the store closest to you your item can be found.  It also tells you its price, the nutritional information, and provides you the recipe, along with others, of how they prepared the vegetable in their buffet.

Many hospitalists do not want to call their patients customers. Those people are hurting how the hospital presents itself to the public.  Maybe it is time for them to go grocery shopping.

You awaken, look outside, and see that the ground is covered with snow.  You did not see it snow, but not seeing it snow does not discount the fact that it snowed.

A patient calls your hospital and over a period of three hours their call is placed on hold and they are transferred from person to person as they try to schedule a follow up appointment.  You did see the person calling, you did not see their bad experience.  You also did not see the hundreds of other people each day who called the hospital trying to accomplish one task or another.

The fact that neither you nor your colleagues saw those people having disastrous patient experiences does not discount the fact that they did.

These types of experiences happen at every hospital every day.  They are unseen and unmeasured.  Nobody in the hospital knows about them.  And if nobody knows about them those bad experiences are treated as though they do not exist.

There are people who know about those bad experiences.  Those people do not work for your hospital, they are your future patients.  Those are the people on Twitter and Facebook and LinkedIn and YouTube.

It has been snowing every day at your hospital and until someone does something about it the snow will keep getting worse.  Either that, or it may be time to by a bigger shovel.

Groundhog Day, the movie.  Bill Murray is trapped in time, every day is the same day, Groundhog Day.

Numbers can be rather interesting.  For example, the number 81 is one of two numbers whose digits, when added and then squared give you the number: 8 + 1 = 9; 9 squared is 81. Or the number 3,435.  Take the digits and then take three to the third, plus four to the fourth, plus three to the third, plus five to the fifth equals 3,435.

Healthcare loves using numbers to measure how it is doing improving patient experience.  Most of the numbers I have seen contain very little information.

The December issue of HealthLeaders Magazine had an article about changing the culture to change patient experience.  The article featured a chart in the HealthLeaders Media Intelligence Report, Patient Experience Beyond HCAHPS.  Nothing to complain about so far, right?

The chart showed what healthcare executives rated as the biggest stumbling blocks to creating an effective patient experience strategy in their organization. It yielded these as the top four issues:

• 49% difficulty changing organizational culture
• 20% too many other higher priorities
•  11% lack of funding
•    8% lack of leadership commitment

Essentially, the leaders’ responses rank the reasons why they are unable to improve patient experience in their organization.  Listing why something cannot be accomplished does not lead to accomplishing it.  Leadership.

Changing organizational culture, 49%.  What if you could dramatically improve patient experience without having to worry one iota about changing the organization’s culture?  Would you do it then?

Improving patient experience beyond HCAHPS requires hospitals to define what is beyond HCAHPS.  HCAHPS happens within the provider’s facilities.  Inside the facilities is where cultural change would occur.  That is the place for which hospitals purchase data and hire smile coaches.  Beyond HCAHPS happens outside of a provider’s facilities.  In general, it does not need to involve people who wear scrubs, and it should not only be about people who have been admitted but not yet discharged.

It needs to involve other people, people who do not work for the hospital and people who are not inpatients.  Who are these people?  They are patients, former patients, and prospective patients.  They are you and me.

Here are the two stumbling blocks those surveyed should have listed about why they cannot create an effective patient experience strategy.  Nine of ten healthcare organizations, that is 90% for those who are not mathematically inclined, do not have a definition of patient experience or a written patient experience strategy.

You cannot have an effective strategy if you do not have a strategy.

The second stumbling block is that in general providers have no idea of the experiences of 95% of the people who interact with their organization.  People whose experiences are unknown, unmeasured, and unasked include:

• Outpatients
• Discharged patients
• Former patients
• Future patients

Some hospitals will try to argue that I am wrong.  Their argument will be based on the fact that they survey this group or that group, or that they have a secret shopper program, that somehow this gives them insight about the experiences of those stakeholders.

There is very little profundity to be gained from surveys or secret shoppers.  None.

If a hospital is serious about improving patient experience it should do the following:

• Define patient experience
• Include all of the stakeholders in the definition, not just current inpatients
• Develop a patient experience strategy

The strategy should include tasks to enable you to answer yes to all of the following:

• Can people access the organization?
• Can they access it when and how they want?
• When they access it can they get the information they need?
• Can they accomplish the tasks they needed to accomplish?

Being able to access the hospital, which in most cases means that someone answers the phone when they call is critical.  Today, many hospitals cannot answer a high percentage of calls.  Of those calls that are answered, they are only answered for a brief number of hours.  Of those callers, whose calls were answered because they called at the right time, a huge percentage of them will not get the information they needed or they will not be able to accomplish the tasks they set out to accomplish.

You do not need a survey to measure their experience, and you do not need the threat of being penalized by CMS to understand their experience.  Their experience was poor.

If you shift some of the execution of those experiences to the web, people get the same results, poor results.  If you design your web solutions correctly, those experiences will be remarkable.

When you can answer yes to these questions you will have improved patient experience.  You will have done so without having to purchase any more data and without having to hire someone to teach your employees to smile.

If you cannot manage to deliver a remarkable experience for someone who is considering purchasing healthcare from your organization, you will not have to worry about surveying that person, about whether the hospital room was noisy or whether the radiology nurse didn’t smile, because the person with the bad experience will never have chosen your hospital.

Patient Experience: A remarkable experience for every person every time on every device.

The CEO of Texas Health Resources stated in the December 2013 issue of HealthLeaders Magazine that “hospitals are used to being accountable for about 4.5 days.”  4.5 days represents the average length of stay for inpatients—I think the use of the word ‘inpatients’ could be considered redundant.

Also in the article is the fact that Texas Health Resources is transforming the delivery of healthcare from hospital-based to community-based including, education, wellness, prevention, primary care, rehab, home, long-term, palliative, and hospice care.

Accountable.  Accountable for care. 4.5 days.  Accountability probably includes reducing readmissions, which includes making sure more people complete more of their discharge orders.

Transforming delivery away from the hospital.

Today hospitals define patient experience as an inpatient function.  Patient Experience efforts must also last on average 4.5 days, and it must not apply much to outpatients or prospective patients.

Here’s where I get confused.  As care is moved from being hospital-centered to community-based I assume that means patient experience will change from being exclusively inpatient care.  It will have to include education, wellness, prevention, primary care, rehab, home, long-term, palliative, and hospice care.  Patient experience will have to be available 365 days a year, 24 hours a day, and on any device.  Essentially at a time and on a device of the patient’s choosing.

The problem is that patient experience like that does not exist today.

You may find education information about a smoking cessation program taped to the wall of a hospital elevator, or via snail-mail, or hidden in a Where’s-Waldo fashion among dozens of other links on the hospital’s web site.

Patients, and prospective patients, should be able to complete dozens of business functions by phone or on the web at any time and on a device of their choosing—access, authorizations, referrals, scheduling, admissions, billing, complaints, refills, discharge—for community-based services like education, wellness, prevention, primary care, rehab, home, long-term, palliative, and hospice care.

Just because patients are not in the hospitals does not mean they are not still your patients.  If you treat them as though they aren’t they will go be somebody else’s patients.

Patient experience needs to occur for as long as the hospital thinks of that individual as either a patient or as a prospective patient.  Sometimes that is over a period of years.

Just because the hospital has never designed that experience or measured it does not mean that the person is not having an experience.  They are, they are just not having a very good one.

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 one of the newsy channels having to do with a Canadian paleontologist sitting by himself on a pebbled beach in Quebec.  His life’s work revolved around pinpointing the place where fish first walked from the sea—the very fact that he was interested in finding out where fish first walked by inference implies his belief 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 reporting that the interesting thing is not that fish walked—which most open-minded non-Darwinians would have found sufficiently interesting all by itself—epochs later; yada yada yada—but that without them (the fish) having walked none of us (the non-fish) would be here.  It was alchemy in paleontology presented in an NPR/PBS authoritative manner, complete with a British accent, and the reporter was his Rapunzel.  If we say it on PBS it must be true.  The show did not offer any opinion to the contrary.  I wanted for someone to pop onto the set and say, “Prove it.”

What troubled me about the show was 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.  I’ve seen Monty Python’s The Meaning of Life and it did not happen that way at all.  The report’s interview of the ichthyologist 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 an ‘uh-huh’ and looked as though she was watching time bend right in front of her Oliver Peoples glasses 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—sometimes I do it with a blog.  His perfervid idea was stranded on the edge of reality and it worked about as well as a poorly used preposition at the end of a sentence.  As I asked blankly of the television show whether any of these walking fish were found wearing shoes, the reporter listened to his promulgation, nodded and followed him into the rabbit hole.  She never questioned whether the compass of his 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, so am I.

Maybe that is how mermaids came to be.

Segue.

A lot of people only care about fixing business problems at the eleventh hour. The problem with that approach is that you never know when it is a quarter to eleven—you only know when it is quarter after.

Leslie Nielsen in the movie Airplane notices the pilot and copilot are incapacitated.  “We need to find someone who not only knows how to fly a plane but who also did not have the fish for dinner.” 

And boys and girls, therein lies the root of the patient experience dilemma—too many of us ate the fish that have been walking around, and we believed everything we were told by the ichthyologists.  They told us that everything you ever needed to know about patient experience could be found by surveying less than five percent of the people who interacted with you, by surveying people who had experiences that went unexperienced by the other ninety-five percent, and whose experiences took place months and months ago.  And who may they be?  They may be and are those who are telling you that they did not eat the fish; the rule makers; those who are selling you your own data; and those teaching your employees to smile more.

You would not build a hospital with only five percent of the materials, you wouldn’t give a patient only five percent of her medicine.  So why spend money on a patient experience strategy that has only a five percent chance of being right?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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