Patient Experience: What Patients Hate The Most

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The world record for the high jump remained unbroken for years.  Do you know what had to happen to break it?  Somebody decided to try jumping backwards…Today we are going to look at how healthcare can jump backwards, not it time, but doing something totally different and far from its comfort zone.

My wife and I had finished having dinner at a nice restaurant and we were waiting for our check.  The waitress brought it.  I looked at the amount and it was only twenty percent of what I had expected. A moment later the wine steward appeared and laid a slip of paper on our table—forty-five dollars.  In turn came the busboy, the sous-chef, the maître d, the dishwasher, the pastry chef, and the head chef.  All told we received eight separate bills for our meal, and no single bill showed the total amount.

To say the least it made for a confusing experience.

When we bought our house, our bill—the settlement statement—showed what we owed down to the penny.  We did not get separate invoices for the plumbing, the windows, the fireplace and the roof.  We also did not get an invoice so detailed that it itemized every nail and every tube of caulk.  Somehow those costs were folded in to other costs.  Do you know how they avoided the problem of multiple bills, paid to multiple contractors with multiple terms?  The builder acted as the general contractor.

It made for a much better experience than if we had been invoiced separately.

Since we all know where this is heading, I’ll head there quickly.

Healthcare:

  • There is no organization acting as the general contractor
  • Multiple invoices from multiple vendors
  • Different payment terms by vendor
  • Different coverage by payer
  • Excruciating line item detail—itemizing Tylenol
  • Nothing showing what is covered and what is owed and why
  • More complexity than a detailed IRS tax return
  • Patients do not know what they owe and to whom they owe it
  • Patients do not know what is covered and why other things are not covered
  • Patients do not know what anything cost ahead of time
  • Hospitals do not know their costs—they only know what they charge
  • Two people having the same procedure at the same hospital will not be invoiced the same amount

The entire hospital billing process makes for an awful patient experience.  Healthcare is the only service someone can purchase without having any idea what they owe and why.  If the amount is large enough it remains an awful experience for months and years until the amount is paid.

I’m guessing, but I would be willing to bet that not one person in fifty in a hospital could accurately explain a patient’s total charges.

The entire billing process could be reimagined, it could be reinvented.  And the reinvention could include a single bill.  For those screaming at their PCs that it cannot be done, the only reason it cannot be done is that it has not been done, and that is not a reason.

Patient experience has to do with dozens of things that are very important to patients, things that hospitals have not changed in decades.

To be the hospital of choice you have to be the hospital people choose, and people will choose the hospital that is the easiest to do business with.

Patient Experience: Part Deux

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Someone wrote to challenge my position on patient surveys in my last post, so I thought I would take another stab at my own thinking.  I appreciate those who take the time to question my position, because I learn best when I hear how others look at the same issue.

I believe the work done by Press Ganey, Studer, and others is important.  However, it seems most hospitals view improving HCAHPs as a means to an end with regard to improving patient experience.  My issues with surveys have to do with what items CMS requires to be measured and with how healthcare providers view and utilize HCAHPs.

Because I have no clinical background, I segment healthcare into the business of healthcare—how it is managed and run, and the healthcare business—the services delivered.  Out of fairness to those who make time to read my blog I limit my remarks to those focused on improving the business of healthcare.

Regarding what CMS require to be measured the following concerns me:

•             Hospitals were addressing and would be addressing these items whether or not CMS felt it necessary to institute penalties for not being rated in the top fifty percent.

•             By definition, no matter how good hospitals become at improving their scores, half of the hospitals will always find themselves in the bottom half.

•             CMS’s survey questions are intermixed with clinical and nonclinical issues.

•             CMS does not distinguish between the relative importance of any two questions; i.e. pain management and clean bathrooms.

•             The survey responses are dated, subjective, and unquantifiable, and the responses require people to use superlatives like ‘always’ and ‘never.’

•             There is no mention or measure of any of the dozens of experiences patients encounter prior to entering the hospital or after leaving the hospital and the effect those have on their total experience.

Regarding how hospitals respond to CMS’s mandates the following concerns me:

•             The majority of the effort made by hospitals improve patient experience includes only improving their HCAHP scores.

•             Improving HCAHP scores is not the same thing as improving patient experience.

•             Hospitals do not focus on, nor do they measure the experiences patients have from interactions unrelated to the HCAHPs questions.

•             Improving the score of a single question does nothing to ‘raise all boats,’ to improve the experiences of all patients.

•             With the hospital’s entire focus on HCAHPs, the hospital has no understanding of the experiences prospective patients have when they try to interact with the hospital.

A final thought.  If high HCAHP scores actually reflect high patient experience—as measured by the responses to those thirty-two questions—why don’t hospitals advertise their scores?  Real people, patients, have no idea what HCAHPs means to them or how their hospital scored.

However, those same people do wonder why the hospital cannot meet their needs when they call, why they are unable to schedule a lab or an appointment online, and why they cannot find their discharge information online.

To me, managing patient experiences based only on HCAHP score is like forcing someone to drive a car forward while only being allowed to look in the rearview mirror.

Patient Experience Surveys: Too Little Too Late?

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I am not a fan of surveys, not even a little bit.  For example, if I included a survey at the end of these comments to see how you feel about surveys, nobody would believe the results would impact my opinion about the value of surveys.  At best it might suggest that at least I appeared to be interested in what others thought.

These are my issues with trying to shape or modify a business strategy based on the information reported in surveys:

  • Most of those being surveyed are no longer your patients or customers.  Once a patient is discharged their ID badge changes—it changes from patient to prospective patient.
  • Prospective patients do not know what changes you have made based on the survey results you obtained because they are not patients any longer.
  • The best results hospitals can hope for by using survey results to drive change, other than trying to avoid CMS penalties, is a campaign that says “although you may not have liked us last time, now that we’ve read your survey responses we think you should give us another shot.”
  • Hospitals are not static.  Healthcare is not static.  Surveys results and Press Ganey data are not current.  The value of trying to implement change based on data that is seven months old would be like NASA trying to get to Mars—it takes about seven months—by aiming the rocket at where Mars is today.  It will not be in the same position in seven months and neither will the hospital.
  • If every hospital is trying to change by doing the same things over and over again using old data, it would seem that the only possible outcome is that their position relative to one another will change.  If you are ranked in the 51st percentile and I am ranked in the 49th and we both try to change our scores based on survey data, aren’t we equally likely to have scores that are pretty similar to each other.

Imagine that at HIMSS 2014 CMS holds a reception and one representative from every hospital attends.  Along with your drink coupon you are given a dart.  At the end of the room is a large cork board, and above the board is a banner titled “The Patient Experience Challenge.”

The CMS representative throws the first dart.  The position of your dart as compared to the position of the CMS dart determines whether or not you will be penalized.  The fifty percent of the hospitals furthest away lose.  Now here is where it gets interesting.  Everybody retrieves their dart and we run the contest again.  If we did that I am guessing two things would happen:

  • On almost everybody’s second throw the dart will end up in a different spot from where it was on their first throw
  • Most of the people whose throws were close to the CMS dart will still be those closest to the CMS dart, those whose darts were furthest away will still be furthest away, and many of those who were borderline will exchange places.

It seems there is little merit to scoring better than the 49th percentile.  I write that because the goal of what is being contested is to avoid the CMS penalty.  If we are being candid we know that raising patient experience scores is not the same thing as raising patient experience.  The two tasks require different strategies, focus, and different resources.

The hospital that wins the patient experience battle is the hospital that chooses to do what their competitors and peers are not doing.

The Patient Experience Disconnect: Two Guys Walk Into a Garage…

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I recently started using the mobile health application MyFitnessPal.  It allows me to enter the foods I eat, track my exercise, and it calculates my fitness and future weight.  Their database includes almost any food that can be purchased or made. 

It allows you to scan barcodes of foods and it knows what constitutes the size of a single serving.  This is proving to be a bit of a problem.  For example, according to the application a box of Rice-a-Roni would be enough to serve almost everyone in Tibet.  That comes to about one grain of rice and one piece of roni per person.  I tried to enter into application that the sixteen-ounce bag of Doritos counted as single serving.  My phone started to vibrate—I think that is how the application laughs.

Based on what you ate, at the end of each day the application forecasts what you will weigh at some future date.  Last night it told me that if I kept eating at my current pace it would cancel my account.

Stop me if you’ve heard this one.  Two guys walk into a garage…

Forty percent of people use one or more of the forty thousand health applications available for mobile devices.  Most of the applications, as rudimentary as they may be as far as their ability to improve one’s health, are designed for people who are interested in living healthier and longer.  At this stage of the game what is noteworthy is not whether or not these apps are effective. 

What is noteworthy is that people want digital and mobile tools to help them live healthier lives.  Two people working out of their garage can get more people to download their health app and use it every day than a five hundred bed hospital can get people to revisit their website once a quarter.  That is significant.

People are looking to the web to live healthier lives.  As we move closer to population health, ACOs, and home care people are seeking guidance and information from people they have never met, from organizations they have never heard of, organizations that have no bona fides.  They are not seeking that help from hospitals because when they have looked to hospitals to provide it the information has not been available.

A hospital will tape a flier to an elevator about their smoking cessation clinic.  Hospitals may post a link to a weight-loss video on their web site.  Hospitals offer good programs, much more credible programs than are available from these health apps, but these programs are closely held secrets.  They are secrets because there is no awareness.  Nobody looks to hospitals first for an interactive way to help them be healthy.  In the same way that people want to get better, they want to find the way quickly.

While there is plenty of lip-service, a hospital’s mindset, its focus, at least when thought of by patients and prospective patients is that these types of services are incidental to its primary mission.  Think about what you do when you have symptoms you do not understand.  Is your first choice to go to your hospital’s website to learn what they are?  Probable not.  You go to a place like WebMD, you go to Google, or Facebook, or YouTube.  We rely on discussion groups and chat rooms of former patients, people we have never met.

When it comes to getting healthy and staying healthy hospitals tend to be the solution of last resort.  Many people become hospital patients only after they have exhausted their own abilities to source the problem.

People, patients and prospective patients, go to websites and use apps because the experience they receive from those sources, while not exceptional, are better than no experiences.

If two guys in a garage can drive people to use the apps or the website they built why can’t hospitals?  Patient experience comes in a lot of forms and for these types of experiences hospitals aren’t offering much.

Many of the patients hospitals receive are the result of purchasing decisions those people made based on information they collected from somewhere other than the hospital.  If hospitals want to be the go-to providers, the repositories of information, their mindsets must change.  Hospitals need to learn how to drive “stickiness” and to control the dialog.  

Patient Experience: What Is The One Question Nobody Is Asking?

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Today’s blog is brought to us by the letter D.

There are things patients think that they do not tell the people who work in hospitals.  Some, but not many people who work in hospitals know what patients think.  The more senior the hospital person, the more acronyms they have on their business card, the less likely they are to know.

Here is a hint.  The people who answer the phones, and the people who do the billing know them.  And I bet they have tried to share their knowledge, but nobody listens to them.

The physicians, nurses, therapists, dieticians, and laboratory technicians all know what their patients think about their healthcare.

The people who answer the phones, the people who do the scheduling, those doing the admitting, and those doing the billing and collections know what their customers think.

The person doing all of this thinking is the patient.  It is also the customer.  The patient is the customer.  They are both patient and customer.  But very few people on the clinical side, and perhaps fewer still in executive roles seem to get it.

Patients have to accomplish two things when they deal with the hospital.

  1. They have to be treated by the hospital
  2. They have to do business with the hospital

Their experience, the total quality of their encounter with your organization (TQE), the bit about whether they will ever return, will ever refer your organization, will pay their bill, is the level of satisfaction of their combined experiences of A and B.

If you are exceptional at treating patients—A, and someone finds that you are exceedingly difficult to do business with, that someone will not do business with you again.

You know your level of patient experience—A—down to a gnat’s eyelash of accuracy.  You beat it up like you are playing whack-A-mol.  You measure it, you have committees empowered to improve it, you buy data to analyze it, and you hires coaches to improve it.  Smile.

How easy are you to do business with?  Oh, really?

I think it is fair to say that almost nobody at a senior level knows if your hospital is easy to do business with—B.  Nothing is measured, there are no committees, and it is not being analyzed.  Heck, there probably has not been a project in the last three years that has even asked the question.

If this question has not been asked and innovatively answered since tablets became common place you do not even need to ask the question. You are not easy to do business with.

If you spent more money on your lobby than you spent on your digital and mobile (think website and customer portal—not the same thing as your patient portal) strategy, you do not even need to ask the question.

You are not easy do do business with.

When Hospital Leakage Turns Into a Flood

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A connection of mine on LinkedIn who is undergoing chemotherapy at Baltimore’s top hospital wrote to tell me that between treatments she called the hospital to schedule an appointment. Between being on hold, having her call transferred, and being given different numbers to call it took three hours for her to schedule the appointment.

Because the hospital failed to perform a simple business process over the phone she told me she will make it her life’s mission to tell people, whatever their illness, to get treatment at another hospital. The hospital will not retain her beyond this illness. A loss of retention and referrals. They cannot put the toothpaste back into the tube. The direct cost of the call to the hospital—thirty dollars. The cost in lost revenues to the hospital for not being able to deliver the expected level of satisfaction will probably be six figures.

There is no universal patient experience solution. HCAHPs is doing good, but hospitals were addressing those issues prior to CMS imposing their strictures. From where I sit HCAHPs does not pass the test of being both necessary and sufficient.

I am trying to raise the discussion to suggest that patient experience is more than HCAHPs. If we look up ‘patient experience’ in the dictionary it should say something other than HCAHPs. I use the Total Quality of a person’s Encounter (TQE). I use person instead of patient because the largest group of stakeholders who have experiences with a hospital are prospective patients, those who ‘visit’ the hospital online and by phone.

I define TQE as follows:

TQE = HCAHPs + all of the nonclinical touchpoints

The nonclinical touchpoints begin before a person is admitted, they begin when people are selecting a healthcare provider, and they continue after discharge.

Most people limit the impact of the Affordable Care Act to payers. Yes, people will be able to choose their payers. Hospitals need to recognize that many people will choose their payers based upon the hospital where they elect to be treated.

Today hospitals cannot even track leakage, let alone figure out how to curb it. Under the ACA people will be issuing virtual RFPs for healthcare, and if their experience on the phone or on a hospital’s website is not remarkable that hospital will be out of the running before if ever knew it was being considered.

I believe that within three years the best hospitals—those that offer a remarkable experience every time on every device—will be those that a person can carry that hospital’s functionality around on their iPad, just like they can carry around the functionality of Amazon today.

People feel they are paying a hospital for two things:

• Outstanding care
• Ease of doing business with the hospital

While outstanding care is valued higher than whether the hospital can answer their phones, if they cannot answer their phones they may not be given the opportunity to showcase their care.

How Are HCAHPs Leading You Astray?

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I dropped by the Minute Clinic for my flu shot.  The forty-something woman ahead of me, whose purse was the size of a small Winnebago, stepped up to the kiosk to sign in.  I may have mentioned in a prior post that I was at the back of the line when God was handing out patience.  After five minutes I began to get a little exasperated.  Her ability to interface with technology reminded me of a chimp learning to play the bagpipes.  Knowing she was going to be a while I retreated to the shaving aisle, grabbed a can of shave cream, a razor, and cleaned myself up a bit.

While the Minute Clinic may be a Godsend for parents in terms of convenience, cost, and immediacy, the user experience (UX) could be improved.  What user experience?  The one that has to do with their automated sign-in. The user interface (UI), although childlike in its simplicity takes more time to complete than the exam.  Your hospital’s website is probably chocked-full of UX and UI opportunities.

Moving on.

Observation may be one of our best teachers, but by failing to observe what we see every day, what is commonplace, we often miss what can be learned from it.  Here is a real-life example that occurred to me from having watched a human interest story on the local news about neighbors banding together to try and rescue someone’s pet cat that was stuck in a tree.

Ladders.  Catnip.  Clawed rescuers.  The cat eventually came down of its own accord.

Here is the observation; have you ever seen a cat skeleton in a tree?  What can be learned?  Maybe cats do not need rescuing.

Innovating patient experience has many similarities with cats stuck in trees.  Somebody overthinks the problem, regulates it, and we throw resources at the problem trying to avoid the regulators.  We establish committees, have meetings, and create reports.  We discuss the problem, we recall what happened the last time we had this type of problem, we bring in experts whose skills are particularly attuned to solving this problem, and then we attack it.

The one thing we fail to do is to validate whether the problem as defined by Washington, and the solution, as defined by Washington—raising the scores of thirty-two questions—is the right approach. This approach presupposes that higher scores are reflective of higher patient experience.  Is it possible that higher scores are simply reflective of having figured out how to avoid CMS’s penalty?

Thirty-two.  A very precise number.  Thirty-one questions were not enough.  Thirty-three would have been one too many.  Thirty-two questions was just right—sounds a little like Goldilocks and the Three Bears.

Those thirty-two questions do not address anything the patient may experience before coming to the hospitals or after leaving the hospital.  They do not address what type of experience prospective patients, people who want to buy healthcare, have when they call the hospital or look online for information about the hospital.

This link takes you to a brief deck listing questions about someone’s experience that were not asked by CMS.  The answers to these questions affect whether someone will buy healthcare from your organization, whether they will buy it again when they require additional care, and whether they will refer your organization to others.

http://www.slideshare.net/paulroemer/step-aside-hcahps

I have done the math.  The financial benefits of getting favorable answers to these questions far exceeds the financial penalty imposed by CMS.  The best you can do by scoring well on CMS’s questions is to avoid a penalty.  The best you can do by scoring well on my questions is to add revenues.

You decide how you want to play it.  Meanwhile, the cat in the tree is doing just fine and does not require any help. If it does, there is always gravity.

Patient Experience: “You can leave your shoes on”

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One of the best parts of my day is when it is announced that consultants are being released back in to society.

As one who flies frequently I have become attuned to what I can do to shave seconds off the gauntlet of passing through security.  I no longer bring a gallon jug of Old Spice in my luggage, and I try to remember not to wear cufflinks that I cannot reattach to my shirt without having to request assistance of a fellow traveler.

As such, and thanks to our friend the underwear bomber, I begin to disrobe the moment I exit my taxi.  On Wednesday at O’Hare I was wearing little more than my freckles as I made my way to TSA’s Death-Star chamber.

“You can put your shoes, and everything else back on,” the agent told me.  I and the other semi-nude people around me wondered if this was some kind of trick.  Would they Taser me the moment I stepped into the chamber still wearing my belt and my dignity?

It turns out they were testing a new way of screening people.  Someone had created a new user experience.

My taxi driver, a man named Ron of Ron’s Taxi, had also created a new user experience.  From what I could tell about Ron he had only been in the US for a brief time. He barely spoke English but I understood he had been driving a cab for most of his life.  I handed Ron my credit card and he slid it through the thing-a-majig that was attached to his phone.  Thirty seconds later he handed me his phone and asked me to enter my email address so the application could send me my receipt.

I share these two instances because they made a very positive impact on my user experience and because there are still a lot of people riding the That Will Never Work Here train.  One VP of strategy even went so far as to comment that rather than innovating hospitals we should effect to bond more with their patients as a way to bring down readmissions.

Now, I like a good bonding experience as much as the next person, but I tend to think of it as a rather poor metric for measuring did we or did we not bond.  Instead of asking a patient if the reason they did not follow their discharge orders was because we did not bond well, perhaps we need to get to the point where patients and prospective patients can carry their favorite hospital around on their iPads just like customers and prospective customers do with Amazon.

When deciding how to reinvent how we approach patients it is too easy to get sidetracked by subordinate clauses around things like HCAHPs.  Why are there thirty-two questions?  Why not thirty-one or thirty-three.  Let us not be led astray by an ounce of fact.

Everything You Need To Know About Patient Experience

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Which of the following statements are false?

  • Forty-eight percent of us believe aliens have visited the earth
  • Thirty-four percent of us believe in ghosts
  • One percent believes the earth is flat—“I put a post in a hole and adjusted it until it was level. That means the earth is flat.”
  • Eighty-to ninety percent of hospitals CEOs believe improving patient experience is one of their top three objectives in the next three to five years.

I can believe the chair next to me will support my weight, but unless I actually sit in the chair merely believing is not worth anything.

Hospitals would have us believe that what is important to consumers of healthcare is that the product—healthcare—is the same as the process of interacting with it or buying it are one in the same, or their belief that process has nothing to do with it.

Take flying for example.  Airlines want us to focus on the product, getting us from Point A to Point B.  They do not want us to focus on the fact that they will charge you if you use your flotation device, your flight will be late, and that they have packed more people into the plane than were in your high school.

My hospital has a website, let’s move on.

The US economy has developed a dependence on digital performance, including the twenty percent tied to healthcare.  Healthcare, hospitals in particular, have developed a digital illiteracy, independence, or naive indifference on all things digital and on all things related to process.

Believing that because your hospital has a website means it understands the impact the digital world should play in its business model is like believing that reading Oliver Swift gives you keen insight into what it is like to be an orphan.

The C-Suite needs to understand that technology is not the same as digital; in fact they have little in common.  In a hospital technology equates to cost—to back-office functions, to supply-chain, to why ICD-10 may be a disaster, and how it is possible to spend three hundred million dollars on EHR and see productivity take a nose-dive.

Digital is different.  It is not some emergent trend.  Please do not stop reading here even though many will disagree with what follows.  Digital is Amazon and eBay, but not in the way most people think about them.  It has nothing to do with CDs, movies, or laptops.  It has nothing to do with what they sell or the price at which it is sold.  It has everything to do with the process by which customers act with what is being sold.

The process, the processes are everything.  They are everything that the processes within a hospital are not, everything that the health exchange is not.  The processes are:

  • Intuitive
  • Easy

And the processes are intuitive and easy because they were designed to be that way.  We are not talking about tweaking things.

The less you understand about the importance of having a remarkable digital presence the less likely you are to have one.  Hospital executives may understand it least of all.  The poorer your understanding, the poorer the delivery of your product is, and the poorer its perception is in the marketplace.

And to make a bad story worse, by the time your hospital gets it your competitors will have already passed you by.

We are not talking about being better at what you are—the grammar is poor but the intent is not.  The discussion that your customers are begging for, the discussion they expect is about your hospital becoming what you are not.

And what does being what you are not look like?

In less than three years every hospital process, every single nonclinical function that is performed today by nonclinical employees will be performed by your patients and by prospective patients.  Every process will be performed without waiting and without error and without much cost.  It will performed digitally and on a device and at a time of the person’s choosing.

Your customers will carry your hospital around in the purses and briefcases.  And that is how I define improving patient experience.

Reinventing Patient Registration

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Healthcare, whether at the largest hospital in the country or at the smallest doctor’s office, begins with the same business process—waiting.  And the bigger the institution the more likely they are to repeat that process during your stay.

To me the registration process reminds me of how I feel when I fly into a city and the pilot, who a second ago was patting himself on the back for an on-time arrival then says that we have to sit on the plane because our gate is not available.  The airline, who scheduled the flight, has known for a month that this plane would be arriving at this time on this day and would be parking at the occupied gate. 

The hospital has the same a priori knowledge.  Someone at the hospital knew what time each patient would be arriving because the hospital employs the gatekeeper.  They know it so well that most patients can call the hospital days or weeks in advance of their scheduled appointment and be told the exact time and location of that appointment.

Let’s agree to do this—it’s pretty far out on a limb, but that is where the fruit is.  Let the patients schedule, admit, and register.  Please don’t say that can’t be done. It is more accurate to say it has not been done.  To those who will say it’s too hard to do, grammatically they should be saying it’s too difficult to do, other industries do it, and a lot of very profitable clinics, clinics with very high patient experience ratings do it.

Create a mobile application that allows me to open it on a tablet at a time of my choosing.  Using the app I view appointments for my doctor or lab and book it.  The app tells me what I need to do prior to arrival.  I enter my insurance information and complete any online forms, perhaps even providing an electronic signature.  The app gives me some form of bar-code that I store on my device.  And when I arrive at the hospital I display the bar code on my device, and hold it up to the hospital’s scanner.  The scanner completes the registration process, displays where I am to go along with accurate directions about how to get there, and even prints out my wrist band.

That allows the hospital to reclaim the waiting room area and get rid of all of the outdated copies of The Economist and Highlights magazines.