Why Patient Satisfaction is like Spilt Tea

At one time the single word Lubyanka was enough to bring normal Russians to their knees in terror.  Lubyanka is known best for being the headquarters of the Soviet secret police.  The basement of Lubyanka housed a prison which contained one hundred and eleven cells, cells used to hold and interrogate political prisoners during Russia’s purge.

Tea was provided to the prisoners twice each day.  A prisoner within each prison cell would place a teapot outside the cell. A prisoner, carrying a pail filled with tea, would pour tea from the pail into the teapot.

Tea spilled on to the floor.  The prisoner would clean the spilt tea with a rag.

Lubyanka’s prison operated for twenty-seven years.  Tea was served to the one hundred and eleven cells and spilled in front of each cell twice a day, seven hundred and thirty times a year.

Two million, one hundred eighty eight thousand spills.  The same number of cleanups.

Someone somewhere made the decision that it was easier or cheaper to spill and sop the water 2,188,000 times than it was to make pails with spouts on them.

What are the pails in your company?  What dumb, wasteful, redundant activities and processes have been left unchanged?

The most obvious one for most companies is call centers.

It is easier to take 2,188,000 calls each year about your bills than it is to fix the bills.  It is easier to take 2,188,000 calls each year about the bills than it is to get rid of the bills.  The same argument applies to a number of other processes.

And do you know where the fallacy in the argument is?  The fallacy comes from the erroneous belief that by having a call center, by answering calls you are actually providing your customers a service.

You are not.  Most times all you are doing is wiping up spilt tea.

Why HCAP Scores Do Not Work

The worst part of being a consultant is when your client makes you walk three steps in front of them and requires you to shout ‘Unclean’.

Sharks cannot turn their heads.  Sometimes it seems business leaders have the same problem.  What transformation or innovation would you undertake if you were not afraid to turn your head, to look for solutions if you were not of failing?

Hospitals either have satisfied patients or they do not.  Measuring satisfaction will not yield satisfied patients any more than Comcast’s ‘Customer First’ program got them satisfied cable customers.

This may come as news, but hospital executives do not need satisfied patients.  The term ‘patients’ is a plural, and no patients satisfaction program will satisfy the plural.  The very notion of having a satisfaction program should signify that the organization, in fact has, a patients satisfaction problem.

Permit me a moment of sacrilege.  Forget the patients.  The doctors and nurses have your patients covered better than any other country on the planet.  Patients do not complain about the MRI.  Patients do not complain that the hospital replaced the wrong hip.

If a hospital is not to worry about the satisfaction of its patients, how then will it improve satisfaction?  Take out your highlighter and underline the next sentence on your monitor.

Worry about your customer.  Focus on the business processes that affect a single customer.  At least half of patient satisfaction is comprised of things that have nothing to do with why the individual is at your facility.  Patients know the clinical experience will not be fun.  They know before they get to the hospital, even if they have never been in a hospital, that the clinical experience will likely be painful, intimidating, scary, and somewhat dehumanizing.

Where hospitals seem to miss the point is that hospitals assume that the satisfaction of a patient’s entire stay is tied to whatever clinical procedure they underwent.  That kind of perspective is somewhat akin to the Ritz Carlton assuming that the satisfaction of a hotel guest’s entire stay has to do with the success of the presentation they delivered at the Xena Warrior Princess Lookalike Convention.  It does not.  Their satisfaction depends on the cumulative of all of the other experiences they had at the hotel.

Something to file away.  Every Ritz Carlton employee, down to the lowest on the org chart, is authorized up to two thousand dollars to do whatever is required to satisfy a customer, even a customer whose bill will only be five hundred dollars.

Patients view their medical procedure and their medical tests as the clinical part of their stay, a part that in their mind occupies far less than half of the hours they spend at the hospital.  That is the patient part.  It is during those processes that people see themselves as patients.

During their other waking hours, and for most of their non-waking hours, people see themselves as customers.  People paying a lot of money for a service.  Hospital employees do not see these people as customers.  And why should they?  Nothing in their DNA, nothing in their training told them that the warm body in room 207 is a customer of a two hundred dollar corporation.  And these same people base a large portion of their customer satisfaction on their experiences during those nonclinical hours. 

I realize this notion of the customer-patient/patient-customer flies in the face of everything hospital employees have been taught.  It certainly flies in the face of the business processes that have been designed to support a patient-only model.

Here is one way to view the distinction.  Patients get better or they do not.  Getting better, fixing their problem is what the patient expects; anything else is failure.  How that happens is the concern of the hospital.  Getting better is a black hole in the mind of the patient.  For the most part patients expect it will not be pleasant.  Patient satisfaction in not all wrapped up with whether the procedures the patient underwent were was painful. It can be argued that a patient’s satisfaction of their clinical treatment is somewhat binary.  Came in sick.  Walked out better.

On the other hand, patient/customers are evaluating their customer experience.  Patients measure their customer experience from before they check in until after they are discharged.

Total patient satisfaction is the sum of a patient’s patient experience and their customer experience.  HCAP is only measuring a portion of it.

Patient Experience Management–Manufacturing Consent

Manufacturing Consent

Foxnews reports “Russian police say they have discovered the body of a local politician reported missing last week, in a barrel of cement in a garage near Moscow. Another politician has been accused of ordering the murder, over an $80 million debt.”  So, we’ve got that going for us.

This weekend I caught a bit of NPR’s “Wait, wait don’t tell me.”  One of the guests was Al Gore.  Oscar winner, recipient of the Nobel Peace Prize, a Tony, and an Emmy. The host neglected to point out that Mr. Gore, former vice president of the United States and Internet founder is standing in line to cash a check for one hundred million dollars from Al Qaeda’s (Al Jazeera’s)—you say potato I say potahto.  I know I promised not to cross the line, but that is why you read this and not some missive from the CMS.

What does it mean if when you Google a topic all of the hits to that topic link to you?  It may not mean much if the topic you Googled is “sliding revolving doors.”  But what if the topic has slightly more potiential.

I Googled—v. past tense of Google—the term “Family Experience Management” and every returned URL is to something about which I wrote.  Just so you know, the groundswell begins today.

Perhaps before we get too carried away we should define Family Experience Management (FEM).  FEM is the set of interactions a “family” of a patient has regarding a family member’s interaction with various components of the healthcare system; providers, payors, pharmacies, Medicare.  It is the superset of interactions for patient experience management (PEM).

Most PEM efforts I have studied are like shutting the barn door after the horses get out.  I happen to think there is much greater value in stopping the processes that have led the way to opening the barn door in the first place.

There is reality and there is perception, and with regard to PEM, rarely the two shall meet.  Some things are just true, perception be damned.  That is why what is right should always supplant who is right.  That a majority of people within any given organization have the objectivity of an insider is why the top two prevailing business rules are ‘we can’t do that’ and ‘that will not work.’

A little dissent can be a healthy thing.  Or not. 

One of my favorite axioms is ‘You don’t ask directions from somebody who has never been where you’re going.’

I am a fan of a good adage, so let us try this one on for size.  A hospital executive falls into a hole—the ‘w’ is silent.  Someone from CMS walks by and the man in the hole hollers, “I’ve fallen and I can’t get out.”  The CMS acolyte tosses down a check, and the man replies, “What is this?”

“That’s some of the ARRA Meaningful Use Lottery. We’ve got tons of it that nobody is going to collect.

An hour later a seven sigma guru passes by.  The man in the hole hollers, “I’ve fallen and I can’t get out.”  Seven Sigma man tosses him a set of workflows and a stop watch and departs.

Days later a consultant happens along.  Recognizing the man’s plight the consultant hops into the hole.

“Why did you do that?” Queries the man.  “Now we are both stuck.”

“No worries,” says the consultant.  “I’ve been down here before and I know the way out.”

Sometimes, perhaps way too often, we get trapped by our own thinking.  By the misguided belief that we already know the correct solution, or we know that the one being proposed will never work.  This is like having my son telling me he does not like broccoli even though he has never tried broccoli. 

We get caught up in the notion that we already have a vision of how we want the world to be and we are willing to do anything to make the world conform to our vision.  We limit ourselves to the possible, to what has already been done.  If however, we limit ourselves to the possible, how does progress happen?

We need to be saved from the shortsighted politicalization of our own intelligence; progresses’ Catch-22.  Once everyone thinks they are thinking out-of-the-box, are they really, or have they simply moved the box.  Sometimes it is best to be the person advocating for coloring outside of the lines.

Patient Experience Management can benefit greatly if only a handful of people began to color outside of the lines.  This link is to a presentation of mine on SlideShare I have given on how to improve patient experience management, something I also call Patient Equity Management. 

You can download it or use a yellow highlighter to help you recall the tasty bits.

I welcome your thoughts, especially learning why you may think I may be all wet.

Thanks Al for making file sharing possible.



When Patient Experience Management Fails-call the cable guy

(This missive is somewhat long—this is where my mind goes when I run.)

Ever watch the show “This old House”? Something magical happens to a man when he watches somebody single-handedly rebuild a 6,000 year old home in a 30 minute program. After that no task seems too complex. As a normal male the first rule of thumb is to remember that having a master’s degree from a reputable university qualifies you for about anything short of brain surgery. The true Type A will often carry that step further by reminding himself that given another week or two of study that even neurosurgery would not be that difficult.

I did a project in one of my prior homes. It involved the simple task of rearranging bedroom furniture one Sunday afternoon; 15 minute project, total cost—nothing. After all, how difficult could that be? The truth is the actual moving of furniture involved nothing more than I’d planned. Only when I thought I was done did I notice that the television set was now located a good 20 feet away from the cable television outlet. The obvious solution would be to simply move the furniture back to its original position.

Can’t do that. To move the furniture back to the original position is either admitting defeat, or admitting I wasn’t bright enough to realize that the cable outlet and the television would be on opposite ends of the planet by the time I finished. Besides, my wife had already seen the new arrangement and if I moved it back to its original position I would have to explain why.

So when she enters the room and asks why (and she will ask why—that’s her job) there is now a 25 foot piece of black coaxial cable snaking its way diagonally across her bedroom carpeting I had better be prepared to answer. Sometimes if you’re quick, real quick, you can try and bluff your way around the problem with a technical answer. You can try and explain that all of the static electricity that was created by sliding furniture across the carpet has caused the sonic membrane surrounding the fiber optical transponders in the coax to be 6 ohms off the medium allowable temperature variation for the building codes in your neighborhood. It is called stalling, allowing for a brief period of self-correction.

The truth, having failed me, the only other option left was to try something close to the truth. I’m forced to say I knew the cable would be at opposite ends of the room before I moved the furniture. My plan all along was to call the cable company and ask them to come to the house to install another outlet on the correct wall.

It’s my wife’s job to inquire how much it will cost—she did not fail me.  This is a clear case of me answering her question without bothering to think. It is important to have a clear understanding of the underlying issues before trying to resolve the problem. I mentioned it should cost forty dollars, and we will only need to leave the cable strewn across her bedroom floor for a few days. It’s then her job to say if we put the furniture back where it was we can solve both problems in twenty minutes. Besides, the cable technician left a mess the last time they did some work, and she wasn’t going to spend more money for poor service. Stay with me here, this is how it becomes her fault, and how it relates to the topic of Patient Experience Management (PEM).

Once her issues were out in the open was a simple matter to devise a solution to address them.  The solution needed to be implemented quickly and it needed to be free. My answer came quickly—too quickly. Eighty percent of the problem could be handled by simply running the cable along the floor board, and then under the bed. That only left five feet of cable between me and a happy marriage. Unfortunately, the five feet in question is from the foot of the bed to the television and runs across the major walkway of the room, looking all the while like an undernourished blacksnake.  Did I mention she hates snakes?

Undaunted, I asked for a little assistance to move the bed. This accomplished, I headed for the garage to find exactly the proper tools for the proper job. I returned five minutes later, tools in hand. I was surprised to see the look of dismay on her face. As it turns out, her dismay resulted from the razor blade knife clutched in my hand. After twenty minutes of the best Boolean logic I could muster, I convinced her, or at least myself, that it would be a simple matter to cut a small hole in the carpet and force the cable underneath. After all, the bed would hide the hole.

The only other tool I thought I would require was a roll of duct tape and a 4’11″ broom handle.  Women know we are confused about how to proceed the moment they see men rely on the duct tape gene. Most men, when cornered believe enough duct tape, properly applied, can serve as a panacea for anything up to and including world hunger.

You’ll note I specified the exact length of the broom handle. It’s only after having attempted the project that I’m able to relate the length of the handle. Most men on a project, especially those being watched by their wife, wouldn’t bother to measure a length any more than they would ask directions while driving across Borneo with half a tank of gas.

As it turns out, I should’ve measured both the distance the cable had to travel under the carpet and the length of the broom handle prior to taping the cable to the handle and shoving a 4’11″ broom handle under a five-foot expanse of wall-to-wall carpet. The fact the carpeting was wall-to-wall is key to understanding what lay ahead. Let’s make certain the situation is spelled out clearly; the new carpet in our new home had a hole in it, a broom handle was now nicely buried under the carpet, and my wife was perched on top of the bed like one of Macbeth’s three witches waiting to see what I would do next.

Walking to the wall and grasping the carpet as best I could, I pulled up a good 10 feet of it from the tacking, acting all the while like I would have to have done that even had the handle not been one inch too short. Leaning with my one arm on the newly exposed carpet tacks, I solicited help in excising the handle from beneath the rug. That accomplished, and dying the death of a thousand cuts, I looked for another proper tool to complete the task. Walking through the kitchen to the garage I spent a moment wondering if the proper tool could be found in the kitchen. Naturally, it was—one half of a pair of chopsticks or, as it’s now referred to in technical terms, a broom handle extender.

Five minutes later, the broom handle extender and cable was firmly duct taped to the broom handle and once again shoved under the carpet. They both went in, but no cable came out the other side. So, I pulled the handle back out and surveyed the situation. The situation, as it turns out, was that in my hand was a perfectly good broom handle, a piece of coaxial cable, and no broom handle extender. The extender was now smack dab in the middle of the 5 foot expanse I was trying to cross, the problem being it was on the wrong side of the carpet, the underneath side. It was positioned perfectly. It was too far under to be reached from either end. In other words, the chop stick just became a permanent fixture in our bedroom.

Certainly, one small chopstick hidden beneath four hundred square feet of carpeting was not a big problem to me. It was not a problem unless you happen to be walking barefoot across the carpet and you happen not to be the one who put it there.  It became not unlike the fable The Princes and the Pea, and my princes found it immediately. In the fable, it was the princes could not sleep. In my case, I knew the non-sleeper in the story would be me for as long as the chopstick remained under the carpet.  Keeping my eyes focused firmly on the task at hand, I foolishly believed if I could resolve the cable problem, the matter of the chopstick would resolve itself.

One final trip to the garage led me to return with a second broom handle. The peanut gallery looked on in disbelief in my ability to finish what I had started without having to sell the house at a loss before I was through. The “I told you so’s” were being thought through in most of the major dialects of the Western Hemisphere.

This had ceased to be a project—it was now a quest, no lesser than that of the Holy Grail. A mile of duct tape later, both broom handles were firmly attached to one another. Even if I destroyed every square foot of carpeting in the house, I would not lose this broom handle under the carpet.  A minute later the cable emerged exactly where it should have, on the other side of the room.  I pulled the out broom handle, attached the cable and turned on the television. Everything worked, just as I had known it would.

Standing in front of the television, admiring my work in the new room arrangement, I noticed I was now a good foot taller than when I began the project. Was this an illusion brought about by my success?  As was quickly pointed out by my princess, my enhanced stature was more attributable to the fact that all of the carpet padding that used to lie between the end of the bed and the wall was now nicely compacted into a ball.  The ball of padding was located in the same twilight zone the chopstick found, right in the middle of the walkway. Trying to correct the problem only made it worse. Each time I prodded the ball of padding with the broom handle it grew larger underfoot. Within minutes it looked as though I had managed to suck up every inch of padding from every room in the house and placed it between my wife and a good night’s sleep. Resorting to logic once again, I quickly pointed out that she should walk on it because she would no longer be bothered by feeling the chopstick underfoot.

The next day I was on the phone scheduling an appointment with the carpet installation service. The carpet installer had to pull up most of the carpeting in the bedroom to be able to reach what she had affectionately labeled Chopstick Hill. I watched him work and I learned all about carpet padding and the installation of hardwood floors. He explained it was lucky for me that he came over because our padding was not good quality padding and we would not have known that had he not pulled up the carpet. I asked him why, if we would not have known about the padding, we would want to spend $300 for new padding. Without responding, he just kept slamming his knee in the carpet installer, charging one hundred dollars for his efforts and my education.

I was so impressed with his discussion of hardwood floors I almost bought one on the spot to surprise my wife. By now, we both know she wouldn’t have appreciated the surprise. Anybody who did not want to spend forty dollars on the cable repairman would probably have a little more trouble accepting five thousand dollars for a new floor.

However, I walked around with a silent smirk on my face for days knowing had we done it my way from the start, called the cable man, we could’ve saved the hundred dollars and never put a hole in the carpet.

This is what can happen when your patients decide to bypass your customer service because of prior bad experiences they have had trying to solve a problem.  It usually comes down to process, bad process.  Processes are a lot easier to fix than disappointed patients.


How to cure poor patient experience

Listening to NPR I heard the columnist from the LA Times, David Lazarus, recount the experience of his recent stay at the UCLA Medical Center, a result of his cat trying to devour him.  Fifty-two thousand dollars; four thousand a night for the room and there was no HBO—more than the cost of the Premier Suite at the Beverly Hills Hotel.  Remember this little fact about the room; we will come back to it.

For any given patient, the highest that patient’s satisfaction will ever be is the moment it exits the hospital.  The likelihood of increasing patient satisfaction after leaving the hospital is no better than the chance of counting backwards from infinity…twice.

What happens, you see, is that while the patient is in the hospital the hospital believes it exercises some sort of control over the relationship.  Perhaps this is where the notion of patient experience management originated. 

Patient experience and patient satisfaction are always being managed.  Sometimes the management of the patient is proactive and deliberate, other times it is managed neglectfully or inadvertently.  Just because the experience is being managed does not mean the outcomes will be favorable.  Unfortunately, this surprises some executives.  Perhaps this should be a ‘predictable surprise’.  When the patient is discharged the patient reassumes control.

What if patient satisfaction and patient experience could be managed effectively for all patients?  Assuming healthcare was a business, what if patients were treated as assets—patient equity management (PEM)?  Business is not a four-letter word in healthcare.  Hospitals market to attract patients.  Why not have programs to increase patient equity management, to retain patients and their families over their lifetime? 

Why not institute a program of family experience management, family equity management?

Viewing a patient non-clinically, there are a handful of major business processes each patient encounters, processes like admissions, scheduling, meals, billing, and claims.  Each of these processes impact a patient’s experience and satisfaction.

Let us jump back to the point about the four-thousand dollar room, not the charge itself, rather the room.  A hospital’s nonclinical business processes can be mapped almost one-to-one to those of large hotel.  One difference one finds when comparing the business processes of a hospital to a hotel is that the satisfaction levels as measured against those processes of the hotel will almost always be higher.

When patients use social media to comment on their stay at a hospital, these are the processes on which they comment.  Patients rarely complain about the doctor replacing the wrong hip.  They do however complain about receiving the wrong meal or about not being able to understand their bill.  Hospitals have no weapons with which to defend themselves against the electronic 1’s and 0’s of poor satisfaction; the internet is forever.  The hospital’s only defense against poor satisfaction is to improve the patient experience.

Mr. Lazarus from the LA Times met with the president of the UCLA Medical Center to discuss his bill.  The president told him that not only did he not understand Mr. Lazarus’ bill, he did not even understand his own bill.  Mr. Lazarus noted that in his article and on NPR.  The circulation of the LA Times is slightly above a million.  No amount of effort is going to put the toothpaste back into that tube.

Some, who feel their way along in near-perfect darkness, have what might be described as the fatally limited hypothesis that there is not much to be gained by improving nonclinical processes.  The individual with a single hypothesis about how to improve matters feels more comfortable with the status quo. 

I am in the process of meeting with a dozen hospital executives to discuss what can be done to improve their nonclinical business processes. If you would like to include your organization in this process please let me know.