Patient Experience, Social-CRM & Russian Salad Dressing

I was settling in to my first bite of overstuffed pastrami and corned beef sandwich—apologies to the vegetablists.  One of the four octogenarians seated in the booth next to me was speaking loudly to the other three about the catheterization he underwent the prior day.

Thankfully, his friend, who was eating the egg salad special interrupted him and asked, “How long have you known Bernie Westoff?”

“I don’t know Bernie Westoff,” replied the cath patient.

“He is one of your LinkedIn contacts.”

“How do you know that?”

Egg Salad stated, “I looked at your contacts.”

“Who told you you could look at my contacts?”

“You set it up that way.  Everyone can look at them”

This conversation continued for the next several minutes.  I was tempted to pull out my iPad, open the LinkedIn app, and join the fray, but instead I kept my eyes straight ahead and worried about the Russian dressing dripping down my arm.  Crowdsourcing 101.

I think the one application of crowdsourcing most overlooked is one which hardly fits the definition. This type is not premeditated and it does not originate within a company. More often than not, the company is the target of this type of crowdsourcing—Social-CRM.

Most definitions of crowdsourcing involve a call going out to a group of individuals who are then gathered via the call to solve a complex problem—problem solving—much like the Law of Large Numbers.  The crowd is likely to have an upper limit in terms of the number of members. By default, traditional crowdsourcing is fashioned to work from the top down; it is outbound, a push model.

Social-CRM (S-CRM) tends to work from the bottom up. There are no boundaries to the number of members; in fact, there can be thousands of members. Also atypical is the fact with S-CRM no single event or call to action drives the formation of the crowd. The crowd can have as many events as it has members.

The unifying force around S-CRM is each member’s perspective of a given firm or organization. Members are often knitted together by having felt wronged or put-off by an action, product, or service provided or not provided by an organization. Most organizations do not listen to, nor do they have a means by which they can communicate with the S-CRM crowdsource. This in turn causes the membership to grow, and to become even more steadfast in the individual missions of their members.

In traditional crowdsourcing, once the problem solving ends, the crowd no longer has a reason to exist, and it disbands. With S-CRM crowdsourcing, since the problem never seems to go away, neither does the crowd.

Every hospital and payer has one or more S-CRM groups biting at its ankles, hurting its image, hurting the brand, causing customers to flee, and disrupting the business model. Even so, most organizations ignore the S-CRM crowd just like someone ignores their crazy Uncle Pete who disrupts every family gathering.

The fact that your hospital may have a Facebook page and a Twitter account managed by two people who are officed in what used to be a supply closet will not do much to dampen the whinge factor created online by those individuals wondering digitally about why the hospital seems to have so much difficulty even answering its phone to schedule an appointment.

Social-CRM is not a fair fight. Perhaps the best approach is to find out why people are complaining, and then develop a plan to fix those issues that have them screaming the loudest.

 

Patient Experience: What Patients Hate The Most

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.

When Hospital Leakage Turns Into a Flood

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?

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.

The Ten Commandments of Patient Experience

According to social media mavens, people are a lot more likely to read your blog if the title includes phrases like the five best, the six most, and seven things you should never do.

Hence, the ten commandments of patient experience.

When I began commenting about improving patient experience I drew comparisons of a hospital’s business processes to those in the hospitality industry, and I was liberal with my use of the word customer instead of patient.  Readers used to throw metaphorical tomatoes at their monitors.  Over time that angst subsided, was replaced by indifference, and most readers began to accept the notion that having a heretic in their midst was the new steady-state.

Few have accepted the notion that most hospitals ought to at least augment their patient experience focus to include what happens outside of the hospital—prior to admissions and after discharge, and fewer still are paying any attention to the largest group of stakeholders—non-patients.

After all, patient experience for non-patients is a non sequitur.  Or is it?  Most people who are discharged change their status; they change from patient to prospective patient.  For them to become a patient again, to be treated for something new or to undergo a new procedure, the hospital must acquire them. 

The unique thing about prospective patients is that all of them reside outside of the hospital.  If your patient experience focus is entirely within the hospital you have no idea what experiences those people have and whether or not those experiences are even satisfactory, a poor benchmark by anyone’s standards.

What are those unmeasured and unreported experiences?  They include access in all of its forms.  Scheduling, admissions, second opinions, billing, complaints, labs, and discharge.  They happen online and on the phone. 

And, if they do not happen well, they will not happen again.  Those people, whose experiences of trying to do business with the hospital are poor, will go somewhere else.  Those people, the hospital’s assets with a lifetime value of between $180,000 to $250,000, will move that asset to another hospital.  They are the same people who cost less to acquire as patients than do the ones who are not even looking at your hospital’s website or calling the switchboard.

Anyway, back to the commandments.  There is only one—

A remarkable experience for every person every time on any device.

How Can Reinventing Patient Experience Decrease Readmissions?

As I was going up the stair, I met a man who wasn’t there.

Then I read an article espousing the ROI of EHR.  I leave it to you to decide if these two activities are one in the same.

I also read an article on reducing readmissions in this month’s HealthLeaders, Readmissions: The Big Picture.  Perhaps it is because my synapses do not work the way they were intended to work, but the first thing that came to mind for me was How could Patient Experience be reinvented to help contribute to the goal of reducing readmissions?  Could deliberately coloring outside of the lines help to solve a real problem?

It absolutely can.  One reason patients readmit is because of their failure to comply with their discharge instructions.  They do not do what they are supposed to do, they do not do it with the frequency with which they are supposed to do it, or they do not understand what to do, who to contact, how to contact them or when when something goes akimbo.  And worst of all, nobody at the hospital knows anything about these failures until the patient is readmitted.

Many of us have been discharged.  I remember the discharge process as the only thing standing between me and the front door.  I would have nodded to anyone and signed anything to be home and to have the hospitalization behind me.  I would read the fine print once I was paroled, once I had a real television remote in my hand, not some off-white three-channel device that was tethered to the hospital bed.  Is it possible that more than a handful of patients feel this way?

Since you cannot give patients a test to confirm they understand their instructions prior to discharging them, and you have no control of patients once they leave, is the situation hopeless?

Patient experience continues once patients are discharged.  Or it could.  Post discharge, most patient experiences—and family experiences—consist of calling the hospital for a variety of reasons; understanding discharge instructions, scheduling a follow-up appointment, scheduling a lab, understanding a bill, filing a claim—reasons very similar to those encountered by patients before they are admitted.  Unfortunately, the people being called may not know the right answer to any of these questions.  Unfortunately, the line may be busy; it may be after hours, or during the lunch break.  Access 8 a.m. until 6 p.m.

They call the hospital.  How well did that work?  If the answer is not well, they may be on their way to having a very poor experience.  If it concerns their discharge instructions they may be on their way to being readmitted.

Here’s how we can tie reducing readmissions to patient experience.  It is not complex, it does not require and MD or a PhD, and it is not really all that innovative unless innovation means looking at solving the problem in a way that differs from the way solving problems is normally looked at.

It is all about access, two-way access.  Two-way access between the hospital and the patient.  Digital and mobile access.  Twenty-four by seven.  I know you do not do it this way, and the natural reaction to this idea is that some of you will have a long list of reasons why this cannot be done or why it will never work at your hospital.  It won’t work for people who do not want it to work, or who may not have the skills. One invalid excuse for it not working is not because it cannot be done.  It can, someone just has to tell someone to make it happen.

Let us take a non-natural reaction, just for a minute.  I envision the following—this is not exhaustive, it does not come from hours of research.  It is just a back-of-the-napkin idea that I would like your opinion as to whether it is worth another napkin or two.

What if the complete discharge summary, and everything patients needed to do, could be available to the patient and the primary care provider in real-time, at the time of discharge?  What if the patient’s behavior and compliance could be recorded, tracked, and reported?  Online access.  Perhaps on an iPad type of device.  Let’s use me as an example, me, the guy who was in too big of a hurry to get discharged to pay attention to my instructions.

Now that I am home I read the instructions.  I register on the website using some form of secure ID that pulls up what I need.  I read about my medications—what they are for, when I have to take them, possible side effects.  I discover that I can track my recovery progress on the site, enter when I take my meds, record when I may have exercised or gone to therapy, perhaps enter what I ate, my blood pressure, and weight. 

Maybe my wife logs in and helps me schedule an appointment, therapy, or a lab. If I schedule a lab the site tells me my instructions prior to having the lab work done, and I provide an electronic signature to confirm my understanding of those instructions.

If I have questions I use the online chat function, or I submit a question that will be replied to within an hour.

My primary care provider can access my progress.

This is certainly not an exhaustive list of tasks, and it deserves more consideration than the twenty minutes it took to write this post.  However, if you pair the idea of decreasing admissions and increasing access, and do so using user-centered design to create an intuitive user experience you may be surprised by the results.

What Does Remarkable Patient Experience Look Like?

My mother would tell me, if a good idea goes in one ear and out of the other there must not be anything in its path to block it.

Procrustes—nicknamed the stretcher and the subduer—was an hotelier, well sort of.  Procrustes’ problem was his bed, his iron bed.  He told his invited guests that he only had one bed, and like Goldilocks, it turns out that his bed was always either too short or too long.  I should let you know that Procrustes’ actually had two sizes of bed.  That way he could ensure himself that his bed would never fit his guests.

He was not a very good host as his tendency towards sadism demonstrated.  Once a person agreed to spend the night Procrustes’ task was to make sure his guests fit the bed.  Those guests who were too tall were shortened; the shorter ones were stretched.

Something defined as Procrustean produces strict conformity by ruthless or arbitrary means.

Iron beds. HCAHPs.  Strict conformity by ruthless—CMS penalties—or arbitrary means—thirty-two questions that do not begin to cover the breadth of a person’s experiences with a health system.  Approaching it this way may make it seem everything is in harmony, and hospitals know they are all being held hostage to the same standards, no matter how wanting or abridged those standards may be.

For those who enjoy movies, one of my favorite lines comes from The City Slickers—we don’t know where we’re going but we’re making really good time.  Aren’t we though.

What if CMS added a 33rd question to HCAHPs?  The question asked of the patients—“What percentage of the time were all of the lights in your room working?” Indeed.  Here’s what I think would happen.  Press Ganey would sell you your data telling you just how many lights were not working.  The Studer Group would offer coaching services about fixing the lights, and your hospital would form a committee to figure out how to raise your scores.

When it is spelled out like this it is easier to see the fallacy of confining yourselves to the responses of thirty-two survey questions as the sole determinant of how people perceive your hospital. Why not use twenty-nine? Why not one hundred and eight?  Is every hospital identical?  Can all of the important experiences be so nicely bundled and wrapped with a bow?

Of course they cannot.

Think about access.  Patient access.  Family access.  Physician access.  HCAHPs do not address access.  Is that because access has no bearing on the experience and satisfaction of patients and prospective patients?  If access has a bearing, one might argue it has even a greater bearing than lights that always work, bathrooms that are always clean, noiseless hallways, and smiling staff.  If people cannot access the hospital using the time and means of their choosing then it is not easy for them to do business with it.

Access should be scored as follows—A remarkable experience for every person every time on every device.  Remarkable is easy to score.  The score is binary, it was or it wasn’t.  you do not put an initiative in place to take your remarkableness from a score of 7.23 to 7.33.  you put an initiative in place to take it to remarkable.

Where does your hospital score on access with regard to being remarkable?  What is your hospital doing to improve it?