While working in Rio we received a briefing from former members of MI-6 and the Secret Service about how to work and play in South America.  If you were going to be kidnapped, Colombia, they told us, was the best, because the kidnappers treated it as a business and they would do their best to keep you alive.  So for Christmas, I took my family to Colombia.

The woman next to me on the flight to Medellin was watching the movie Proof of Life.  The movie was about a woman living in Colombia whose husband is kidnapped.  Ironic?  I hoped so.  It reminded me of the scene in the movie Airplane when the people on the plane were watching a movie about a plane crash while their plane was about to crash.

I knew little of Colombia other than from a combination of impressions formed from watching the movies Clear and Present Danger and Proof of Life.  The US perception of Colombia was that there were guerrillas hiding behind every banana plant.  Readying myself for a run through the mountains I knew I would have to rely heavily on the fact that I owned a Navy SEAL t-shirt, and that I had seen a television series on SEAL training on the Discovery channel.

I carried with me a bottle of dehydrated water as I made my way up the mountain.  My escape plan, if push came to shove, was to build a hang glider using my shoe laces and by weaving together leaves from one of the tropical plants.

The run proved to be uneventful.  Colombia was amazing, exceeding my expectations.

Nowadays nothing exceeds ones expectations.  A handful of firms meet your expectations, but what firms do not know is that we have lowered our expectations so much that meeting them is still unsatisfactory.

If someone at any organization asked me what my expectations of doing business with them were I would reply that I expect to be disappointed. I feel that way about trying to business with my hospital.

If this is your first time reading my blog, I have been called the Stephen Hawking of Patient Experience,

I have been a heart patient for eleven years.  During that period I have spent a total of four days in the hospital, way less than one percent of the time.  For the other four thousand days I have been having experiences with the hospital; scheduling appointments and labs, checking-in, ordering refills of my prescriptions.

The thing is, none of the ten thousand employees knows about my experiences, or knows if they were good or bad.  The reason nobody knows is because nobody has asked.  And the reason nobody has asked is because the hospital is not required to be aware of my experience, and more importantly, it is not penalized if my experiences are poor.

Patient experience reminds me of the commercial about Las Vegas—What happens outside of the hospital stays outside of the hospital.  Hear no evil, see no evil, speak no evil.

In other words, don’t make waves.  If you were a mariner you would be familiar with the word doldrums.  The doldrums are a period of inactivity; no wind, no waves; the same thing day-in and day-out—Groundhog Day.

It is week 17 in the NFL.  I was listening to a few interviews on ESPN of players whose teams are still in contention for the playoffs.  Every person interviewed said that they were going to treat this last game as though it was a playoff game.  Really?  They play sixteen games.  Now that there is nothing beyond tomorrow they are going to treat their last game as a playoff game.

What if they had approached game one or game six as a playoff game?  Would they still have to treat game sixteen as one?  Had they won any single game that they lost maybe the outcome would have been different.  In September players say they are playing to compete in January when everything is on the line.  Perhaps they should notice that if they do not play like everything is on the line in September they will not have to worry about January.

We do that in healthcare. We treat patient experience that way.  We wait to learn the results of the next round of surveys, then we make a plan, then we try to implement the plan.  Civil wars were won and lost in less time.  It is like reading yesterday’s paper to learn yesterday’s news.

It’s time we make a few waves—if you do not nobody else will.

I wrote and posted this in December of 2009.  Rereading it this morning it made me wonder how far we have come. What do you think?

‘Twas the night before Reform when all in the House

Were Tweeting and blogging and squawking like grouse.

Their bill filled with zeroes and commas and flair

In hopes that the Senate would soon be there.

The voters were restless, and in need of good care,

And they whined and they pleaded and they yelled ‘don’t you dare.’

“Don’t sidestep this issue, don’t do it for votes”

“Don’t kowtow to payers or we’ll be at your throats.”

With Pelosi and her Botox and while Reid took his nap

Didn’t care if the people put up with their (you rhyme it, I’m pretending to be neutral).

The docs sat on the sidelines, bemoaning their fate,

While payers dressed like succubi caroled “ain’t this great?”

On the lawn of the White House there arose such disdain,

As the public fought reform from ‘Frisco to Maine.

MSNBC, neigh now Comcast, buttressed their base,

And Fox, aka Rupert, said it was all a disgrace.

The words on the pages of the newly printed bill,

Hid nuance, erudition, obfuscation, and skill.

Do not read the details, adjectives and signs,

Do not worry how it impacts your bottom line.

We are here to pretend we did that of import,

To Hell with Medicare, Medicaid and the sort.

It’s voters we want, It’s our doxology, our mantra,

And this year silly people, this year WE are Santa.

On Boxer, on Biden on Fienstein they came,

And we chortled, berated, and chided by name.

“What about seniors, and sick people” we cried.

“What about uninsured, don’t you care if they died?”

“This is about people you meet on the street,

People who must choose between their meds and to eat.

It’s about Lipitor, Xanax, Prozac and Viagra,

It’s about doing what’s right, do what’s right or we’ll bag ‘ya.”

And then in a twinkling I heard in my head,

The gnawing and chiding of Congress, who said,

We cavorted and sucked up, the best we knew how,

We spent bucks, made payoffs, and said the time is now.

Festooned all in new regs from NHS to VA,

There were those who suggested, this is not going to play,

HITECH and ARRA are not making it fun,

RHIOs and RECs will soon come undone.

We’re paying the hospitals to do EHR,

We know it seems silly, like we lowered the bar.

If that doesn’t work we will tax them instead,

Make them spend gobs of money, make their budgets bleed red.

Spend it, refund it, and print new money now,

Buying Canada would be cheaper and easier but wow.

They want to sign something, sign it soon, sign it fast,

But don’t assume that they’ve read it from first page to last.

We could’a been more like France, like the Swiss or the British

Make us more European, make our rich people skittish.

The tall socialist exclaimed as the dems shifted right,

Will Obamacare fail, have I lost all my might?

With the penchant Americans have for all things European I have been wondering if there is a way to make a go of a business that combines Monster Truck events with Pamplona’s running of the bulls.  Could I make money building a business that brought the running of the bulls to cities throughout the US indoors?  I bet you could pour a few hundred truckloads of dirt on the floor of Texas Stadium, get a lot of people to pay for the privilege of trying to outrun the bulls, and fill the seventy-thousand seats at a hundred dollars a seat.  Perhaps we could combine it with “La Tomatina,” the annual tomato fight in Bunol, Spain where 100 tons of overripe tomatoes are thrown in the world’s largest food fight–those Spaniards sure have a knack for having a good time.  We could sell bags of rotten tomatoes at the concession stands.  Maybe the new Fox Sports Network would carry it live.

I spent the last several days in Tampa. I’ve been coming to Tampa since my parents retired there twenty-six years ago.  There has been highway construction each time I’ve been there.  They are still building roads in Tampa, and the construction takes traffic to a standstill. The good news is that you can get to anywhere you need to be in Tampa in ten minutes as long as you are driving a Klingon Battle Cruiser.

Some projects, like Tampa’s road construction, are not designed to end, they just go on and on, and people become so accustomed to the effort that sooner or later they no longer notice it.

Improving patient experience via HCAHPs is one such project.  How many years has your hospital been working at it?  What year is it planned to end?  Apparently there is no statute of limitations.

What is the net value of your investment?  Has there been or will there be return on the investment?  Will you be able to look back a few years from now a say with some degree of certainty that your efforts improved patient experience?  Do the efforts year in and year out seem to be focused on fixing what was already supposed to be fixed?

Best case with HCAHPs, maybe you will be able to look back and say that all you really achieved was avoiding the penalty.

In Tampa when they finish building a road, they move the equipment and the builders to another area and build a different road.  They do not build a road, tear it down, and then build the same road again and again.  That would be silly.

In the event of a water landing your life-vest contains a location light that will illuminate when we slam into the hard as concrete water from thirty-six thousand feet, making it easier for the Coastguard to locate your body.  There was no warning about carrying C4 or RDX in your undergarments or wearing a pair of clogs constructed from match-heads.  I did not know if that was because airlines thought nobody would ever again attempt such a foolhardy method of bringing down a plane, or if they had simply given up on being able to discover the culprit before it was too late.

It is illegal for you to tamper with or destroy the smoke detector in the plane’s lavatory.

Really? They have to issue that warning because on some flight not only must someone have tried to destroy the smoke detector, but because there was no warning about the illegality of it someone was able to use not knowing as their defense.  This is the same reason there is a warning on your toaster telling you not to make toast while you are taking a bath.

There are on hundred and twenty-six seats on this plane.  Therefore the probability of the one screaming child sitting directly behind me was slim.  I was never very good calculating probabilities.

According to the English, the play, Waiting for Godot, is the most significant work of the 20^th century. It is an absurdist play in which two characters wait endlessly for someone named Godot.  Maybe it is like a hundred and twenty-six people waiting for the plane to crash-land in water—I think the term ‘land’ is a bit superfluous. 

I read what Wikipedia contained about the play.  Apparently there are almost as many interpretations of what Samuel Beckett meant by writing it as there are people who read it—everyone has an opinion of everything.  Depending on the person one would think Beckett intended readers to think the play had to do with one of the following; The Cold War, Freud, Jung, Existentialism, Ethics, Christianity, an autobiography, and homoerotica.  I did not know Beckett had such range.

I am always amazed when people interpret what people write, when they try to ascertain the true meaning of what the author, someone with whom they have never spoken, had in mind.  We have built an entire field of study, English Literature, around these empty suppositions.  People with PhDs ask students—students who wonder why they did not study something else—what so-and-so intended when they wrote such-and-such.  Not only do they ask the question, they believe the answer is important.  They will grade the poor student to see if the student was able to spit back the truth as they imparted it.

Here’s a secret about authors and about what they do and why they do it.  They write to tell a story.  That is it.  I write. There is no hidden meaning.  When there are no more words to write, hopefully the story has reached the end.  My son’s teacher asked him why the author of a poem used a certain phrase in a poem.  I told him to tell the teacher the author used it because it rhymed.

If Beckett had wanted people to know what he thought about The Cold War he would have written about it—by the way, for those who thought he was writing about the “Cold War” the phrase barely existed when he wrote Godot.  If he had written an autobiography, he probably would have titled it “Waiting for Godot: an Autobiography.”

Too many of us spend way too much time trying to discover what was really meant by an author or a speaker.  We try to interpret a report.  We read between the lines to find the hidden meaning.  We do that with the patient experience data we purchase.

We have probably learned less from our data than we think, and we spent a lot of money trying to learn more, trying to figure out what else it could be telling us.  Personally, I think all of the things about patient experience that are not being looked at can tell you a lot more than the things that are being studied.

If for example the entire patient experience across the care continuum contained one hundred touchpoints, and hospitals only had data on thirty-two of the touchpoints—HCAHP scores, what could having data on the other seventy-two touchpoints tell us?  What if hospitals knew the experiences of people who were scheduling and appointment, who were being admitted, who wanted a second opinion, who didn’t understand their bill?

Sometimes it is easier to get more data, different data, than it is to squeeze more information you’re your old data.

I am fascinated by the use of robots in healthcare, from steerable micro-robots that travel through veins to precision robots guiding surgeons to the delivery of meals to patients in the hospital.

What makes them so useful is their accuracy.  If they get it right the first time they will get it right the millionth time.  They do not get bored, they do not have an attitude, and they do not need a supervisor.

A robot performs its functions using the computer program that tells it what to do.  Without the program the robot is nothing more than a door-stop.  It is the program that enables the robot to replace or supplement the work that would be done by a person.

I am more fascinated by where robots are not used in hospitals.  If robot technology—think computer programs—can be designed and used to do something as complex as treating someone, as saving someone’s life—the ultimate patient experience benefit, why can’t it be used in other areas like improving other aspects of patient experience and acquiring new patients?

Remember, what makes the robot work, what gives it its value is the program.  So, how do these programs enhance patient experience? Can computer programs possibly provide a remarkable experience for every person every time on every device? Yes, and here is how.

Two ways people access the hospital; on the internet and by phone.

Two groups of people access the hospital; patients and prospective patients—everyone else.

Two experiences people have when they access the hospital; remarkable and unremarkable.

Specifically I am referring to a customer portal—not the same thing as a patient portal, and a call center.  People contact the hospital because they are seeking something, an answer or information, or because they have a complaint they want resolved.  Well-designed user experience programs can provide accurate, high quality responses with a high degree of precision:

• Time after time
• Twenty four hours a day
• Faster
• With zero marginal cost
• Zero rework
• Zero duplication of effort

Call Center:

The call center program is Customer Relationship Management (CRM).  Less than twenty percent of hospitals have a CRM product.  Of those who have it almost none of them use it to manage customer calls; they use it as a sales tool.  The program’s purpose is to enable the people who answer the phones to provide the best answer, the right answer to each call.  The CRM is designed to satisfy the person who calls, and to give them enough of what they want so that the person does not have to call a second time.  It shortens the length of the call, enabling the hospital employees to take more calls.

Customer Portal:

People access the hospital because they want to buy healthcare, or are buying it, or because they have to do business with the hospital.  The rest of the world calls people who want to do business with an organization customers.

For too long hospitals have relied on Information Technology and Marketing to decide what customer experience means to the organization. The vast majority of hospitals do not have a working definition of patient experience. I have not found a hospital that has formally designed patient experience across the continuum of care.  The customer portal is for patients and prospective patients and it should be user-centered and designed by patients.  A customer portal is not for getting information about the gift shop or the board of directors.

The purpose of a hospital’s customer portal is to make it easier for people to do business with the hospital and to decide to buy services from the hospital.  Anything else is just noise.  And the people who know what they need from the hospital are the patients and prospective patients.

What can a customer portal do?

With the right design a customer portal can:

• Perform in-whole or in-part:
  • Preadmissions
  • Admissions
  • Scheduling
  • Discharge instructions, monitoring and compliance
  • Billing
  • Collections
  • Reduce the cost of back-office personnel
  • Increase the accuracy of each person’s touchpoint
  • Greatly reduce errors and rework

I call it iHospital or myHospital.  Everything nonclinical I need from my hospital on my laptop, my tablet and my phone, all in one place and whenever I want it.

The worst thing for your hospital is for it to be the third or fourth one in your market to build it.

To those who would argue that because not all of our patients want to use computers, and for this reason we should not do what you described, I would ask you at what point does it become worthwhile?   Twenty-five percent of your patients, fifty, ninety?  Every patient and prospective patient who goes to your hospital’s website is already looking for a technical solution to give them some or all of what they need.

In another life I could have been Batman, but most days I settle for just being the designated human.

Under the Freedom of Information Act journalists from the Durdge Report discovered an email from the CEO of one of America’s largest health insurance companies to its employees regarding a change in their strategic direction in an attempt to reap benefits from the implementation of the Affordable Care Act.

It read in part:

“The other night my family and I were watching Warren Beatty’s movie, Heaven Can Wait in which Beatty, a former NFL quarterback, is reincarnated as a wealthy CEO, but one with a totally different personality.  During the movie he is meeting with his board and listening to his customers complaining that the firm’s canned tuna subsidiary is killing a lot of porpoises in their fishing nets.  Beatty replies to his board ‘Wouldn’t you pay more to save a fish that thinks?  Let the other firms build plants in the wrong places, let the other quarterback throw a gurgle.  Let’s be the team that makes the rules, that plays fair. It will cost us millions but we don’t care because we’ll come out ahead in the end.’

In my report to our board of directors I noted that there is an entire group of stakeholders that are not being served.  It is not the group everyone is talking about and fighting over, the uninsured, it is the insured.  It occurred to me that our greatest opportunity to grow our business has been right in front of our eyes the whole time.

Annually we spend millions of dollars employing thousands of people to adjudicate claims.  Adjudicate is a polite word for deny.  We have dozens of attorneys working around-the-clock drafting policy loopholes that allow us not to pay our customers’ claims.  We are very, very good at what we do.  But nobody likes us.

Accordingly, I have instructed our marketing department to design a new campaign around our new strategy.  We are going to be the company that plays fair.  We are going to let the other insurance companies kill the porpoises.

We are going to be the company that pays our customers’ claims.  It will cost customers more, but they will actually get what they pay for.  It will cost us millions but we don’t care because we’ll come out ahead in the end.”

When you live in a house of mirrors or fall through the looking glass, the impossible becomes possible.  On my best days I try to solve three or four impossible things before breakfast.  This problem, even when viewed from the land of fantasy does not appear to have a solution.

According to Princeton Survey Research forty-percent of us would rather pay the fine than pay for insurance.  I bet that throws a wrench in Sebelius’ spread sheet.

Oh, and given that only twenty-eight percent of us were uninsured before the Act, the wrench must be huge.  This is sort of like the business strategy that states “We’re losing money but we’re making it up in volume.”

So, potentially when the dust settles there will be more people without insurance than there were before we made insurance affordable.

This means that the price of insurance for the remaining sixty percent will increase.  Therefore, some of those people will drop their coverage and elect to pay the fine.  In business terms this is known as a death spiral.

At this rate by June nobody will be paying for insurance because nobody will be able to afford it.  The insurance companies will be out of business.

If that was the final outcome, I might argue that that is not a bad thing.

But that cannot be the final outcome.  Somebody will step in to provide insurance—just like they do in Europe, only our somebody will have a Washington DC zip code.  I think that was the plan all along, but I am a ‘glass is half full’ kind of guy.

BTW, how’s your French?

The good folks at NPR stated that forty-one states have legislation making it illegal to text while driving—the other nine states are trying to thin the herd.  The commentator mentioned it is almost impossible to enforce those laws.

It is also illegal to skateboard while driving, but this law does not need policing as Darwinism makes it self-enforcing.

Here is how texting and driving ties in with patient experience.  Forty-one states are trying to enforce the law—a hundred million drivers, each moving between twenty-five and seventy miles an hour, a few thousand police officers.  An impossible task.  It is like freeing a hundred cats that were in a box.  How many can you catch?

There is a simple solution to the problem.  Instead of trying to catch each person who is texting why not stop everyone from texting?  Through GPS it is possible to track if the phone is moving.  It must be possible to build an app that turns off the ability to text if the phone is moving.  In other words, do not try to solve the problem one hundred million times, solve it once.

Patient experience.  The present approach to improving patient experience is to solve it a hundred million times.  We ask Sally what she did not like about her hospital stay and then we try to fix it afterwards.  Then we ask Billy.  And Pete.  And Mary Lou Who who was no more than two (Grinch). We only have 999,996 more people to ask and 999,996 additional fixes.

The current approach to improving patient experience has three fatal flaws:

• It is reactive; put out this fire, then put out the next fire.
• You will never run out of fires
• There is no designed global patient experience across the care continuum

The analogy a rising tide lifts all boats does work with the industry’s current approach to increasing patient experience.  For the current approach to work, for patients to feel they had a remarkable experience requires hospitals to implement thousands and thousands of fixes, former patient by former patient.

Why not look for an approach to improving patient experience that only has to be implemented once?  Why not use an approach that creates a remarkable experience for every patient AND every prospective patient every time they access the hospital?

Let’s lift all boats.

• Design a global patient experience across the entirety of the care continuum
• Ensure the design includes:
  • Inpatients
  • Outpatients
  • Prospective patients
  • Ensure the design includes:
    • A digital strategy—the web.
      • Patient portal
      • Customer portal—not the same as a patient portal
      • Social media
• A mobile strategy
• A Call Center/CRM strategy

This is how you get from where you are to a remarkable experience for every person every time on every device.

Please text me your thoughts, but pull over first.

Several years ago I consulted to one of the largest cable television companies—an industry that may be extinct in five years, can you say ‘streaming’—about their marketing strategy. The cable company was excited about their ability to execute marketing campaigns to entice subscribers to subscribe to premium movie packages like HBO and Showtime.

During one meeting they told me about all of the customers who had signed up for a package of HBO and Cinemax for eighteen dollars a month. I asked if they knew whether the campaign had increased their revenues and their chief marketing officer looked at me like I was an idiot—I get that look a lot. 

What we uncovered was that even though thousands of people subscribed to the new package, most of those subscribers were people who had been paying twelve dollars and ninety-five cents each for HBO and Cinemax.  This created a net revenue loss for the company of about eight dollars a month for each person that switched.  This was a classic strategy of “We’re losing money but we’re making it up in volume.”

There is no segue for this piece as none is needed.

The Affordable Care Act.  The next time the government creates a program I am willing to bet it does not give it a title with a built-in oxymoron.  Sadly, the Act has become healthcare’s example of the cable company’s premium movie package.

The stated idea behind the Act was to ensure that more people had access to healthcare.  That was supposed to happen because healthcare would be more affordable—nobody ever promised it would be affordable. The result so far?  Some people who did not have insurance now have insurance.  Many people who had health insurance have lost their insurance.  Others who had it are now being charged more than they can afford and pretty soon they will not have insurance.

If the goal of the Affordable Care Act was to give insurance to people who did not have insurance, they may have minimally succeeded.

If the goal of the Affordable Care Act was to have less people uninsured, has it worked?  Or, has it simply changed the faces of those who are without insurance?  Robbing Peter to pay Paul.

And what about the Care aspect of Affordable Care?  Has Care become more Affordable, or have we become so mired in the insurance aspect of the Act that the intention of making care more affordable has been lost?

If we evaluate the Act honestly, it is not equipped to make care more affordable.  The cost of care has not gone down, it will not stay the same, in fact, it will increase.

It is, and it was from the outset, about insurance.  The Affordable Care Act-has not worked.  The Affordable Insurance Act—has not worked.  The Act was about giving more people access to health insurance.  The mistake the Act’s authors made was assuming payers would be good corporate citizens, was believing payers would act with some degree of benevolence, was believing that payers could be controlled or reigned in.

Cui bono?  Who Benefits?  Three years from now what will we have?  When the dust settles, some without insurance may have it, some with insurance will not have it.  Care will cost more.  Payers will have higher revenues and larger profits.

And what about patients.  Where does this all shake out when it comes to improving their experience?  People who cannot afford healthcare, who cannot afford insurance, will not have an experience that can be measured by HCAHPs or anything else.

This example makes it easy to understand good patient experience, and it makes it even easier to understand what is not good experience.

My daughter and I walked into the office of her orthodontist this morning.  Within five minutes the staff of ten, and the doctor, were serenading a thirty-two-year-old mother of two with a song they had written.  Why?  Because she just had her braces removed.  One the big screen television flashed pictures of the woman, what she looked like before braces and now.  They presented her with gifts, there were balloons, and to eat were many of the foods she had avoided because of her braces.

My daughter checked herself in on some monitor.  She carried with her a cup of wooden nickels that she had earned from her visits over the last eighteen months.  She redeemed the nickels for a fifteen dollar gift certificate; not much a return for a five thousand dollar investment but she was happy.

The orthodontist sends her a birthday card and invites her and a friend to a Halloween party and a spring bowling party.

I’m not sold on the experience for the parents, but the patients are.  And what the heck, we have spent ten thousand dollars, got two fifteen dollar gift certificates, and a slice of pizza at the bowling party.

What makes this experience remarkable and what makes it different from any hospital experience is that this experience was designed, thought through, planned, and executed.

I do not suggest that hospitals sing to the patients or give them wooden nickels.

I do suggest that the entire experience be planned, starting from before they enter the hospital until after they are discharged.

I have been a heart patient for eleven years and during that period I have spent far less than one percent of my time in the hospital.  Yet I have an experience with my hospital even when I am not an inpatient.  And the thing is, nobody has designed any part of my experience.