Target, the Neiman Marcus of North Korea, advertised the color of one of its plus-sized dresses as ‘manatee grey’.  The Manatees were not offended, but apparently Target’s plus-sized shoppers were.  For those who may have opted out of aquatic physiology in college, the term manatee translates to sea cow.

HealthLeaders reported twice in the last three years that Patient Experience Management (PEM) is one of the top three priorities for healthcare executives. A McKinsey survey of 1,000 provider executives showed that 90 percent of executives ranked PEM first or second.

Those results put my mind at ease on the issue about as much as North Korea’s Pak Pong-Ju—I know his name sounds like a video game—claiming its nuclear efforts are only targeted at improving the yield of their turnip harvest.

Recall the tagline of the McKinsey study—none of the hospital executives surveyed knew who in their organization owned the patient experience.  Little was planned for addressing this priority. However, several hospitals were expected to offer more heart-healthy alternatives in the basement cafeteria—leadership. Be on the lookout for the Pak Pong-Ju Turnip-Melt.

Anyway, I digress.

Healthcare’s Watergate. Follow the money. Yet, there is no money to follow, at least not an amount that suggests hospitals view PEM with the same degree of import with which they speak of PEM.

Missing is the planned expenditure that would come even close to making Patient Experience Management a priority. Don’t believe me? Print out a copy of your organization’s strategy, its budget, or its general ledger, and sort all of the planned expenditures from greatest to least. Stop reading when you reach the line item for Patient Experience Management.

Meanwhile, I am going for a run. If you find it before I return, wait for me, but you will not have found it by then.

You did not find the dollar amount budgeted for PEM did you?

In general, money for what seems to be very high operational priorities is dribbling along so slowly as to suggest these initiatives had prostate problems in the offing.

There was no booth at HIMSS to showcase the most singularly spoken of topics—Patient Experience Management. There was not a single PEM vendor. Why? Because the vendors know PEM, for now, is a unicorn—so why bother selling unicorn horn polish?

Thinking is vastly underrated, especially by those who don’t—think, that is.  I am a huge fan of the phrase, “What if?”  Where are all the what-iffers?

On the overrated side are those fixated upon the 2.0’s and 3.0’s.  The dot-oh terms connote a handful of things, none of which are particularly helpful.  Supposedly the dot-oh represents a destination of sorts.  What that destination looks like is anyone’s guess.

It is as though those in the Patient Experience 2.0 club see themselves as having arrived; as being somewhere better than those still mired in the one-dot-oh’s that comprise their cloistered universe.  Maybe it is just a level of enlightenment or attainment which comes from having been to the mountain top.  They Tweet with their David Attenboroughish British accents, revealing tidbits information heretofore unknown to the 1.0 crowd.

May I suggest the problem with the dot-ohs is the notion that there is some sort of deliverable, some point at which one is no longer striving to get to the oh-ness because one has arrived?  Then what?  I think that is why the uptake of the dot-oh concepts by the C-suiters is so low.  Patient Experience 2.0.  Health 2.0.  Social Media 2.0.  Executives are still paying for all the one-dot-oh initiatives, initiatives which for the most part failed to deliver.

Note to reader: There are no end points, no dates in late October where anyone can say with credibility, “We’ve arrived at the dot-oh end point. 

It is a fallacy to believe that any of these uber-initiatives are ever complete or exist in isolation.  I propose we define new nomenclature for initiatives like Patient Experience 2.0, some naming convention that does not have an endpoint.  A transcendental number perhaps, a number with no end.  Irrational.  Pi—π.  Health π.  Patient Experience π.  Social media π.

Better to remain silent and be thought a fool than to speak out and remove all doubt—Abraham Lincoln.

I have the right to remain silent, but at times I seem to lack the ability—Ron White.

Today I am opting to follow Ron’s path, shall we see where it leads us?

I just finished reading the two pieces in the patient experience field that many would feel to be the loadstars on the topic.  One is from on online media publication; the other comes from what many would consider to be the ‘go-to’ consulting firm in the space.

I reread both pieces looking for the part where they tell hospitals how to increase patient satisfaction. I concluded that reading them a third time would not get me what I hoped.  Chances are that if your organization is trying to improve the patient experience someone in it has read at least one of the pieces.

So, shall we toss some metaphorical tomatoes at the monitor?

Every right minded patient knows that their visit to the hospital will at various times have things done for them that will be painful, humbling, humiliating, embarrassing, and frightening.  Patients have the expectation that their clinical experience will be all of these things. Patients may be smarter than we give them credit for being. 

Like it or not, they know their time in the hospital will not be fun.  Patients know they will encounter these feelings regardless of which hospital they choose.  What I mean by that is that patients are not going to say ‘This is the last time I am going to Our Lady of Perpetual Blunders because it really hurt when they replaced my hip.  When I get my other hip replaced I am going to go Joe’s Feel-Good Hospital.’

Patients believe that the hospital’s highly trained medical staff does its very best to provide outstanding care.

The flaw in most patient experience efforts can be tied in part to the fact that patient experience and patient satisfaction need not be the same.  Maybe they are more like twin sons from different mothers.  Is it possible that how patients feel or rate their experience has to do with clinical things, and how they rate their overall satisfaction has to do with the hundreds of other points of contact they had with the hospital?

If that is the case, we are trying to solve a problem containing two unknowns; patient experience and patient satisfaction—something mathematicians will tell you is difficult to accomplish.

Let us use the label TQE to represent the Total Quality of the Encounter.

TQE = Patient Experience + Patient Satisfaction

Patient Experience reflects how the patient feels the hospital performed clinically and Patient Satisfaction reflects how the patient feels the hospital performed regarding nonclinical events.

One part of the TQE equation includes world-class, 2.0 processes.  The other part of the equation may more closely resemble 0.2 processes, processes at which even your cable television operator executes better.

To Improve TQE one must improve the experience and the satisfaction.  Neither single type of improvement meets the test of being both necessary and sufficient.

And here is the kicker.  The patient experience is a summary of different processes for each patient. No two patients undergo the exact same clinical processes.  So improving a given clinical process does not raise all boats, does not improve the hospital’s overall patient experience rating.  Clinical processes have the following characteristics; they are discrete, they relate just to healthcare, and they are not able to be automated.  They are what I call barely repeatable processes, BRPs.

On the other hand, there are dozens of processes, dozens of points of contact that every patient encounters.  Improving one does raise all boats, does improve the hospital’s overall patient satisfaction rating.  Nonclinical  processes have the following characteristics; they affect all or almost all of the patients, they do not relate just to healthcare, and many can be automated.  These are what I call easily repeatable processes, ERPs.

If I wanted to make a big impact on how patients rated the Total Quality of their Encounter, TQE, I would take a hard look at the ERPs.

Five hours until the train arrives in Boston.  Last night I was afraid I might have to cancel the trip, all because of a tie.  Those of you who have played along for a while may remember that I am a Type A and am still able to read at or above my age level.  Yet when I selected the tie for tonight’s dinner I got the ‘You’re not really going to wear that tie with that shirt’ look.

Without flinching, I placed the tie in my bag.  Time will tell if the Beau Brummel, man about town, made the right choice or whether he will be hoisted by his own petard.

It occurred to me that sometimes the most obvious of things prove to be far from obvious.  For example, call centers.  When people call an organization, a hospital, why are they calling?  Think about this before answering.  They are not calling because they want to talk to someone.  In fact, calling an organization is the only time people place a call when they really do not want to talk with someone.

The only reason they call, the only reason the phone is ringing is because they need something, information, information they could have been provided earlier but were not.  Because of that they are forced to do something none of us ever wants to do—call a company, fight the IVR, and listen to a recorded voice tell them how important their call is.  Organizations that really want to mess with your mind will tell you that the call may be recorded for quality purposes.

We call because we want information.  We would walk naked over hot calls if there was any other way to get this information.  Why?  Because we know that half of the time we call we do not get the information we need.  We implicitly agree by calling that we will play Russian roulette with those manning the call center betting that the person who answers the phone will also be able to answer the question.

In general, calls to call centers fall into one of three categories;

• Queries—what time are visiting hours over
• Needs—send me a copy of my bill
• Complaints—this one does not need an example

Let us say your hospital gets one thousand calls a day and that the fully loaded cost to answer each call is thirty dollars.  That means your hospital spends almost eleven million dollars a year to be able to talk to people who are not all that thrilled to have to talk to your people.

Does spending these eleven million dollars every year improve patient satisfaction?  Of course not.

So then, why bother having call centers?  What should the hospital’s vision or mission statement be for its call center?  Do not even think about using phrases like best in class, customer service, retain customers, reduce costs.

From the perspective of the hospital its vision for the call center should be to make the call center obsolete.

Figure out which of the three reasons people call—queries, needs, complaints—and put it online.  Design the heck out of a patient portal using design thinking and UI/UX—if you think about designing something that has the opposite of user experience of your HER you will be on the right track. 

I am talking with a hospital about re-engineering their call centers and CRM.  Their call centers close at six-thirty Monday through Friday.  Patient dissatisfaction.

The last time I checked the Internet does not close.

If a blog falls in the woods and nobody reads it does it make a sound?

When basketball was invented players shot the ball into a peach basket.  When a player scored the game was halted to allow someone to bring over a ladder so the ball could be retrieved from the basket.  The game was very slow.  It was very slow for seven years until someone got the idea to cut the bottom out of the basket.

Suppose someone asks you to give them the Cliff Notes version of Patient Satisfaction.  What is the best way to respond to convey such a complex issue?

There are some 5,000 hospitals in the US.  There are some 2,500 hospitals being penalized for having poor patient satisfaction scores.  As compared to what, did anybody ask the patients?  Use a highlighter or underline this on your monitor—being in the top half of the patient sat scores does not mean that your patients are satisfied with your hospital.

To the chagrin of the ‘six sigmaists’, here is a news flash.  Shaving thirty-two seconds off of the time it takes to be admitted does not yield satisfied patients.  If making the admitting the process shorter is a good thing, would it not make sense that doing away with the patient admitting process would be a really good thing?  Maybe it is time to cut the bottom out of this peach basket.

If your hospital has not recently reinvented how it electronically interacts with patients and potential patients through a world class patient portal, it is way out of touch with how patients interact with other organizations with which they do business.

How would you like to be admitted if you were going to the hospital two days from now?  If you are like me, you would want to navigate to the hospital’s web site the evening before you are scheduled to check in.  You want to pull out your iPad, go to the web site, complete the check in and be given a room assignment.

Patient satisfaction just went up.

To read and complete this post you may use the following tools; graph paper, compass, protractor, slide ruler, a number two pencil, and a bag of Gummy Bears—from which to snack.  The following problem was on the final exam in my eleventh grade physics class.  Let us give this a shot and then see if we can tie it into anything relevant.

A Rhesus monkey is in the branch of a tree thirty-seven feet above the ground.  The monkey weights eight pounds.  You are hunting in Africa, and are three hundred and twenty yards from the monkey.  You have a bolt-action, reverse-bore (spins the shell counter-clockwise as it leaves the gun barrel) Huntington rifle capable of delivering a projectile at 644 feet per second.  The bullet weighs 45 grams.  The humidity is seventy percent, and the temperature in Scotland is twelve degrees Celsius.

At the exact moment the monkey hears the rifle fire it will jump off the branch and begin to fall.  Using this information, exactly where do you have to aim to make sure you hit the monkey?

I used every piece of information available to try to solve this.  I made graphs and ran calculations until there was no more data left to crunch, computing angles and developing new formulas.  I calculated the curvature of the earth, and the effect Pluto’s—the former planet, not the dog—gravitational pull had on the bullet.

The one thing that never occurred to me was that since the monkey was falling to the ground, so was the bullet—gravity.  The bullet and the monkey both fall at the same rate because gravity acts on both the same way.  So, where to aim to hit the monkey?  Aim at the monkey.

All of the other information was irrelevant, extraneous.  The funny thing about extraneous information is that it causes us to look at it, to focus on it.  We think it must be important, and so we divert attention and resources to it, even when the right answer is staring us in the eye.

Attempting to improve patient satisfaction is a lot like hunting monkeys.  We know what we need to do and yet we are distracted by all of this extraneous information that will hamper our chances of being successful.  The most obvious distractions are all of the things we did to improve it other than asking the patient about their expectations.  Hiring the “six sigmaists” to shave thirty-two seconds off admissions is one of those distractions.