HCAHPs

Dying to Improve Patient Experience?

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I stumbled across an article on the La Brea Tar Pits.  For those unfamiliar with them, over thousands of years the gas from oil deposits close to the ground evaporated leaving the byproduct tar oozing from the ground.  As it happens, this oozing is in LA, as in Los Angeles.  To date more than three million fossils have been excavated from the tar, including fossils of saber-toothed tigers and wooly mammoths.

It made me wonder what would happen if tar pits were discovered today in other US cities. My guess is that the EPA would immediately declare the site off limits and establish it as a Superfund cleanup site.  The Feds would look into whether British Petroleum was somehow behind the leak, thinking perhaps that BP simply dumped the oil it cleaned up from the Gulf of Mexico disaster.

Next we have Blockbuster, the video chain that required two trips to their store for every one use of their product.  If you are wondering why there are so many Rite Aids and CVSs in the US, I’m guessing most of them are housed in former Blockbuster buildings.  Redbox will be the next and final video chain to go bye-bye.  Maybe CVS can figure out how to squeeze a Minute Clinic into a box.

Several years ago I attended a convention on customer experience whose keynote speaker was the most recognized CEO in the cable television industry.  A reporter noted that cable television subscriptions had capped at around seventy percent, and remarked that it would not get any larger due to the number of older people who do not use technology and who did not subscribe to cable.  The reporter asked the CEO how the industry would deal with that situation.  The CEO stated “We are waiting for them to die.”

Healthcare does not have the luxury of waiting on anything.  There are those who want to skirt the issue by saying that we have patients who do not use technology, people who do not have access to the internet.  Indeed there are.  However, the converse is true and it is true in much larger numbers.  Applying technology to patient experience is not a binary trap, not an either or situation.

One of the great things about technology is that it is impartial, it does not takes sides, and it is relatively difficult to hurt its feelings.  Plus it has a great memory—it gives the same answer, the correct answer, every time to the same question.

Foresight versus hindsight.  How difficult would driving be if the only view available to the driver was the view from the rearview mirror?  Three years from now the best hospitals will look back at these discussions and wonder why not reinventing patient experience was ever an option.

Three years from now the other hospitals will look back at these discussions and wonder why reinventing patient experience was never an option.

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.

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.

The Ten Commandments of Patient Experience

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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.

Patient Experience: Why is it like Greek Mythology, and why is that bad?

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The pastor was teaching on the book of Leviticus, more specifically the part where lepers had to shout the warning “unclean” as they passed people on the street.  I had a client once who tried to induce me to yell the same warning when I passed people in his office.  Sometimes instead of consulting the idea of being Willy Loman looks pretty good.

Sometimes we decide something cannot be done and our only supporting argument is because they have never been done—meaning we have tried to do them.  Some things are difficult, some are nigh on impossible, and some are impossible.  (I usually try to accomplish two or three things before breakfast.) Greek mythology tells us of Sisyphus, a deceitful ruler who was punished by being forced to roll a giant boulder up a hill, only to watch it roll back down, and to repeat the task forever.

Here is an example of a Sisyphean task.  Place you back against the wall of whatever room you are in.  Your task is to reach the other wall, and every step you take cuts the remaining distance in half.  No matter how many steps you take you will always have half as far to go from the distance of your prior step.

We all have our boulders.  Endeavoring year after year to raise HCAHPs scores and to achieve survey ratings of one hundred percent is healthcare’s Sisyphean task. There are returns, diminishing returns, and no returns.  Is the best scoring the one that places your organization in the fiftieth percentile?  What is the business benefit of being rated first or second?

Children teach us that there is a fallacy created by using superlatives and in measuring perfection.  They begin arguments with phrases like you always and you never.  These arguments are easily rebutted, for all you need is to find the exception, the instance where the tautology does not hold.

There are grossly diminishing returns earned from trying to hit benchmarks around always achieving a goal because you can prove the negative by finding a single false occurrence.

A month ago I was in Los Angeles.  The only thing I recall with certainty is that I stayed in a Marriott, and that the Marriott charged me twenty-nine cents for checking why my message light was lit, a message they left me welcoming me to the hotel.  I do not recall the floor my room was on, the side of the hall on which it was located, whether the employees always smiled, whether the bathroom was always cleaned, the noise level of the room, nor the color of the carpeting. Five months from now I will not be able to remember the name of the hotel.  Can you recall these details from your last trip?

It would be silly of anyone to ask me these things six months later.  If I am in a good mood I might invent positive scores.  If I am in a bad mood, who knows how I would score the questions.  I would certainly discourage the Marriott from taking my input too seriously, and I would caution them from investing any resources trying to change their processes based on my invented responses.

Riddle me this, then why does that seem to be the model under which everyone in healthcare operates, trying to hit Sisyphean standards?  People are asked to score their recollections about something that happened six months ago, that happened when they were in pain, bored, and taking medication.  For them to score their experience of the hospital the most favorably they have to say that something favorable happened one hundred percent of the time.  That is, the hospital was never noisy, the bathroom was always clean, the pain was always managed, and everyone always smiled.

Superlatives.  The wrong measure of success.  The wrong measures of patient experience, retention, and referrals.  Let’s face it.  Hospitals will have noise and employees will have bad days—and the patients know it.  So why then put all of your patient experience eggs in only one basket?

Patients have expectations, prospective healthcare buyers have expectations.  And yet nobody ever asks them about what expectations they have and nobody tries to design experiences around those expectations.

 Image

As an industry we are led to believe that we have our arms around patient experience simply because we are measuring and responding to survey responses, buying data, and hiring coaches.  The questions, and their resulting weights, were developed without ever speaking to a patient let alone speaking to hundreds of patients or prospective patients.

The point is that nobody knows what kind of experience patients and prospective patients expect of any of the contacts and interactions people have with a hospital.  We do not know because we have not asked.

We do not know what people expect to be able to do when they go to a hospital’s website to make a purchase of healthcare.  Clearly people go to a hospital’s website with some purpose in mind.  They expect to accomplish something.  There are dozens of things they would like to accomplish but nobody knows what they are because nobody has asked them.

This is real Patient Access:

I selected twenty hospital websites to see what I could accomplish using their site.  My tasks were simple; view available appointments, actually schedule an appointment, reschedule an appointment, schedule a lab, complete the pre-admission process, learn how to file a claim, issue a complaint, use online chat, download my personal health records, receive a clear explanation of my bill, understand what my procedure will cost me, get information about a second opinion.

Most hospital websites read like reading a Wiki:

I could not accomplish any tasks on any of the sites I visited. I could however get information about the hospital’s board, learn how to make a donation, find out about what hours the gift shop is open, get directions, read the hospital’s blog, “like” the hospital, learn what awards have been given, and learn about the history of the hospital.

People go to the web because they know they cannot get the information they need by calling the hospital.  Then they learn they cannot get what they need from the web.  Where do they go?  Who knows?  The only thing we know for sure is that their expectations about their experiences are not being met.  They also know that nothing is being done about it.

One final thing I did not see on any of the hospital websites I visited was the hospital’s HCAHPs score.  Why is that worth noting?  It is worth noting because if HCAHPs mattered to those buying healthcare, if hospital’s believed HCAHPs are an actual reflection of what patients think of their experience, the scores would be posted front and center.  HCAHPs are not important to patients.  HCAHP scores are not included in marketing letters; they are not posted on billboards, or spoken of on NPR commercials.

Meeting expectations determines whether people will buy healthcare from your hospital.  Improving HCAHP scores determines whether or not your hospital will be fined.

Improving HCAHP scores and improving patient experience are two very different goals.  Only one increases revenues.

The ROI of Patient Experience

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As a parent I’ve learned there are two types of tasks–those my children won’t do the first time I ask them, and those they won’t do no matter how many times I ask them.  Here’s the segue.

Hospitals have a gazillion business systems.  Every business system can include the following three things; people—doing things, processes—the way and order in which things are done, technology—whatever part of those things that may be automated.  Two examples of business systems—ordering your meal in the drive-through lane at Burger King; open heart surgery.

Believe it or not, from a process standpoint, each of the hospital’s gazillion business systems can be sorted into one of two buckets—Easily Repeatable Processes (ERPs) and Barely Repeatable Processes (BRPs).

An example of an ERP industry is manufacturing which executes identical business systems thousands of times—clean the Pepsi bottle, fill the bottle with Pepsi, put on the bottle cap, and place the bottle in the box.

Healthcare, in many respects, is a BRP industry. BRPs are characterized by collaborative events, exception handling, ad-hoc activities, extensive loss of information, little knowledge acquired and reused, and untrustworthy processes. They involve unplanned events, knowledge work, and creative work.

ERPs are the easy ones to map, model, and structure. They are perfect for large enterprise software vendors like Oracle and SAP whose products include offerings like ERP, SCM, PLM, SRM, CRM.

How can you tell what type of process you are trying to incorporate in your effort to improve patient experience? Here’s one way. If the person standing next to you at Starbucks could watch you work and accurately describe the process, it’s probably an ERP.

So, why discuss BRPs and ERPs in the same sentence with patient experience? The answer is quite simple.  Think of BRPs—barely repeatable processes—as those processes associated with HCAHPs; exception handling, unplanned events, and knowledge work.

Think of ERPs—easily repeatable processes—as those associated with all of the nonclinical touchpoints patients and prospective patients have with the health system.  Those include:

  • Scheduling an appointment
  • Scheduling labs & therapy
  • Requesting medical records
  • Getting information about whether a second opinion is needed
  • Admissions
  • Billing
  • Payment
  • Submitting a claim
  • Queries
  • Complaints

Here is what is unique about a hospital’s ERPs:

  • Every time a patient or prospective patient tries to complete one of these processes they have an experience
  • That experience is either satisfactory or unsatisfactory
  • The hospital has no idea if the person was satisfied
  • The hospital has no idea if the person will continue to be or will ever become their patient
  • All of these processes happen outside of the hospital
  • They happen on the phone and on the internet
  • They have nothing to do with HCAHPs
  • Hospitals do not measure these processes
  • Hospitals do not try to improve the effectiveness of these processes

Hospitals behave as though these processes have nothing to do with patient experience.  Just because hospitals do not acknowledge the existence of or the importance these systems have on patient experience does not make them irrelevant.

True story—a Top 5 US hospital.  A cancer patient between treatments who is experiencing the after effects of chemo calls the hospital to schedule a follow up exam.  She spends almost three hours on the phone.  She told me that because of that one event she will never recommend that hospital to anyone.

Now to the meat of the matter; money.  Healthcare may argue that they are not in business for the money.  While that may be true, they are not in business if there is no money.  So let’s talk about dollars.

  • One study concluded that each time someone contacts a hospital the potential revenue in play is seven thousand dollars.  Provide a good experience during that contact you keep the money.  Provide a bad one and some other hospital gets the money.
  • The average lifetime value of a patient is between $180,000 and $250,000.
  • The average lifetime value of a person who chooses a hospital other than yours is zero.
  • The cost of poor experience is low patient retention and very low referrals.

The taxonomy of 99% of existing patient experience business systems is that they are ineffective, unmeasured, and proving awful experiences at the places where people touch the health system—the phone and the web.

Ignoring these aspects of patient experience is no different than having your hospital’s CFO drive down the highway while pouring bags of money from the window.

What do you think?

Are Hospitals Looking in the Wrong Haystack for the Needles?

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“The time has come,” the Walrus said,
“To talk of many things:
Of shoes–and ships–and sealing-wax–
Of cabbages–and kings–
And why the sea is boiling hot–
And whether pigs have wings.”

Gibberish (I thought Jibberish was spelled with a J) is good, and often insightful.

Sometimes I have to rack my brain to decide what to write; other times it is handed to me, just begging for a response.  This is one of the “other” times.

In the fable of “Chicken Little” the chicken believes the sky is falling because an acorn fell on its head—the chicken was wrong.  In the fable “The boy who cried wolf” the people in the village are fooled into believing a wolf is attacking their village.  The people are wrong.

In the CMS fable “Everything a hospital ever needed to concern itself with regarding patient experience,” CMS is wrong.  And to make matters worse, CMS has all of the providers focusing all of their efforts on catching the wolf.  What many do not recognize is that providers would have been doing these things with or without the hard hand of CMS.

It is much more difficult to find the needle in the haystack when you are not on the same road as the haystack.  Hospitals have already found many of the needles.  Their problem is that the remaining needles are smaller and smaller, and more difficult to find.  Thus, finding each subsequent needle costs more.  Hospitals have also missed the fact that right next to the CMS haystack are other haystacks with needles the size of javelins waiting to be found.

Case in point.  Another one of the articles in HealthLeaders’ August issue, “Patient Experience and Cultural Transformation.”  To be fair, the article is perfectly fine and is likely spot-on in its representation of the survey responses it received.  Regular readers of this blog will recall that I also took umbrage with another article in this issue in my post “My review of HealthLeaders’ lead article “New Approaches to Patient Experience.” Where’s the “New”? ow.ly/obdPp.

HealthLeaders is reporting the facts, just like when Sergeant Joe Friday in Dragnet requested “Just the facts ma’am.”

Sometimes the facts do not tell the story.  Sometimes somebody needs to question the validity of the facts. Sometimes somebody needs to ask “What are the implications of those facts?”  somebody needed to have asked those surveyed “Why?”  This is one of those “sometimes.”

The article presented the results of a survey sent to the HealthLeaders Media Council and select members of its audience. Two hundred and ninety-nine completed surveys were received with a “margin of error of +/-5.7% at the 95% confidence interval.”

In the opinion of this writer, the data in ‘quotes’, while likely 100% accurate from the perspective of statistical sampling—meaning they analyzed the responses correctly, is probably 100% inaccurate from the standpoint of the what they should be doing.  At best, what providers are doing passes the test of being necessary, but it does not pass the test of being both necessary and sufficient.  It reflects the reality of what provider executives perceive they need to do to improve patient experience. It is also worth noting that even though the responses in the article were segmented between providers and health systems, patients and prospective patients make no such differentiation when it comes to their experience.

In the sciences, when one gets a result that does not jive with one’s hypothesis it is often helpful to reinterpret the result by multiplying by negative one or by evaluating the inverse of the result.  For purposes of this blog, we are going to do both.

The article reports what its respondents plan to do regarding addressing patient experience.  I originally thought about using the word ‘improving’ instead of ‘addressing’ but I chose ‘addressing’ because I am not convinced that these efforts, if enacted, will improve anyone’s experience.

As an example, what if two customer experience surveys were compared side-by-side.  One for hospitals and one for hotels.  Might they look like this?

HOSPITAL

    

HOTEL

  

What is the NO. 1 goal of your patient experience efforts?

  

What is the NO 1. goal of your customer experience efforts?
         

Improved HCAHPs Scores

36%

  

retaining customers

99%

Improved clinical outcomes

33%

  

getting referrals from customers

99%

Improved market share

9%

  

improved market share

99%

improved word of mouth

7%

  

improved revenue generation

99%

improved revenue generation

4%

      

improved reimbursement

2%

      

other

8%

      

No one is arguing that for hospitals to be successful at patient experience that they need to think of themselves as hotels.  No one is arguing that hospitals should stop trying to manage pain or to reduce noise.  The argument is that there are plenty of other things hospitals could be doing to compliment their current initiatives, things which would have a much greater impact on improving experience.

What is the business problem hospitals are trying to solve as they wrestle with what to do about patient experience?  Are hospitals endeavoring by their efforts to create a remarkable experience for every person every time?  If they were their approach would be entirely different.  Are they trying to retain patients, to earn referrals, to capture a higher percentage of their receivables?  If they were their approach would be entirely different. 

The problem hospitals are trying to solve is to avoid the CMS penalty.  Hospitals’ expenditures of people and capital are not targeted to solve an actual business problem; the expenditures are to avoid a problem created for them.

The HealthLeaders survey asked, and the article reported answers to the following questions:

  • What is the number one goal of your patient experience efforts?
  • In which of the following patient-related areas do you expect your organization to focus over the next three years for patient experience improvements?
  • Please rank your motivations for investing time or resources to improve patient experience scores
  • Who has the primary responsibility for patient experience in your organization?

Permit me to comment on these in the order in which they were presented in the article.

  • The number one goal reported by hospital executives is ‘improved’ HCAHP scores. So, let us assume the hospital achieved its goal and rocketed to the first quartile, thus removing itself from CMS’ penalty.  What do they get from that achievement? Retention, referrals? Nope?

Is this goal not an example of keeping ones focus on the hole versus the doughnut?  None of the responses listed any mention of the word ‘patient.’ Less than one in ten respondents addressed improving market share, not that the planned efforts will do much to improve share. And, none of the responses mentioned making any effort to retain patients or to attract prospective patients. 

According to the survey results, hospitals’ primary focus are on trying to meet an artificial benchmark created by CMS without knowing whether achieving this benchmark is the best thing they could be doing to create a remarkable experience for every person every time. 

What if CMS had decided that those hospitals that had the most number of physicians shorter than six feet tall would be penalized?  Would hospitals fire the height-challenged doctors?  Clearly this is absurd. Or is the analogy comparable? 

  • I am stupefied, but being stupefied has become my comfort zone.  Hospitals are going to focus their efforts exactly where they have been focusing their efforts.  If hospitals all do the same things, and they each improve by a factor of ‘X’, then has anything changed?  Forty percent are going to focus on noise reduction—earplugs—ten cents.  Twenty-five percent on housekeeping—Motel Six can give pointers and they will ‘leave the lights on.’  Better signage?  Please. 

Improving patient experience is an issue that has the attention of most hospitals.  Yet the solutions being proposed seem to be sorely lacking the following initiatives:

  1. Innovation
  2. Transformation
  3. Patient retention
  4. Patient referrals

 

  • Motivation for the effort and expenditure.  If everyone’s motivation is relatively identical, what is the likelihood that the results will be relatively identical—that is, unchanged?  At some point in time won’t the height of every hospital’s physicians be six feet or taller?

 

  • Who is responsible for patient experience?  In three percent of the hospitals the chief experience officer is responsible for the experience of the patients.  Am I missing something here?  Does that mean only three percent of hospitals have this position, or is the position merely rhetorical?  Would the cafeteria manager have scored as high or higher.

Who is responsible for the experiences of the prospective patients? Apparently nobody.  Who is responsible for the experiences of people before they come to the hospital, after they are discharged, and of those wondering if they should seek a second opinion from another hospital?  If hospitals cannot agree as to who is responsible for their current assets (patients), then we can be certain that nobody is responsible for the experience or satisfaction of prospective patients (their future assets) or for those patients seeking a second opinion.

Glaringly absent from the response categories for this survey question are the roles of chief marketing officer, sales, and business development.  If that is a true reflection of the answer to the question of who has the responsibility, then what exactly is the responsibility of those organizations?

The tallied survey responses seem to be all about raising HCAHP scores and avoiding penalties; not about improving the experience or patients and prospective patients.  Does that seem to be the case in your organization?

I have corroborated my analysis estimating that the lifetime value of a patient is somewhere between $180,000-$250,000.  That means that a prospective patient is worth the same amount.  Add to that the revenues of a patient’s family and friends and all of a sudden we are looking at numbers that demand innovation and transformation around patient experience.

Patient Equity Management. Family Equity Management.

A remarkable experience for every person every time on any device.  If this is your goal, the value of having your primary focus be reducing noise, housekeeping, and signage needs to be rethunk.

Improving Patient Experience: Why not try something new?

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Success and failure are often separated by the slimmest of margins. Sometimes success hinges on how you present your idea. It is possible to force the circumstances via rapid evolution to pass from problem, to possible solution, to believable, to heroic? I believe so.

Permit me to illustrate with frozen chicken. Several hours before dinner I threw the frozen chicken breasts into the sink, choosing to thaw them with water instead of the microwave. Some twenty minutes later while checking emails I wondered what we were having for dinner. Not to be outdone by own inadequacies, I remembered we were having chicken. I remembered that we were having chicken because I remembered turning on the hot water. The only thing I couldn’t remember was turning off the hot water.

I raced to the kitchen. My memory of having forgotten to turn off the water was correct. Grabbing every towel I could find, I soaked up the man-made lake that had appeared on the hardwood flooring.  While draining the lake I thought about how I might answer to my wife if she happened to return to a kitchen during high tide. My first reaction, admittedly poor, was to tell her that I thought the countertop wasn’t level and that the only way to know for sure was to see which direction the water ran. Telling her the truth never entered my mind.

Once the major puddles had been removed, I worked on version two of the story, quickly arriving at a version of the truth that seemed more palatable—tell her I decided to wash all the towels. Why not get bonus points instead of getting in trouble? Version three looked even better. Since I was wiping the floor with the towels, instead of telling her I washed the towels, why not double the bonus points? I decided to wash the floor, and wash the towels. Husband of the year couldn’t be far off.

A few hours have passed. The floor is dry—and clean, the towels are neatly folded and back in the linen closet, and the chicken is on the grill. All the bases covered. A difficult and embarrassing situation turned into a positive by quick thinking.

A few of you have asked, let’s say we buy into what you are saying, how do you propose we create a remarkable patient experience? All kidding aside, it comes down to presentation. Clearly you can’t walk into a room with a bunch of slides showing that with all of your hospital’s efforts you have only managed to improve the experience of the patients from 7.25 to 7.27.  

The first requirement to turn stalled patient experience scores into a remarkable experience for every patient and every prospective patient every time is to quit focusing only on HCAHPs.  Think of it as a patient experience 12-step meeting; “Hi, my name is Paul, and my patient experience scores have flat-lined.”  See, that was not so difficult. 

And what needs to be done?  Why not take a deep breath and decide that the time has come to lead and innovate, and to stop relying on CMS to define what patient experience means for your hospital?

Here is a start for those looking for the first step.

Define the Total Quality of a person’s Experience (TQE). I use person instead of patient because prospective patients also have experiences when they visit family members, when they call the hospital and are on the web trying to decide where to buy healthcare.

TQE = Patient Experience (think HCAHPs) + Persons’ Satisfaction (all other touchpoints)

So, how did my chicken dinner turn out? I was feeling confident that I had sidestepped to worst of it. Overconfident, as it turned out. My son hollered from the basement, “Dad, why is all this water down here?”

 

Patient Satisfaction: Why Hospitals Are Losing the Battle for Patient Revnues

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Sometimes you choose to write; other times you have no choice but to write. This is one of those other times.

For those of you who believe most business situations can be tied to something related to Mel Brooks you will appreciate this. In his movie History of the World Part One, Brooks plays the role of Moses descending from Mount Sinai with stone tablets of the fifteen commandments.

http://www.youtube.com/watch?v=8YX-gqRdK_8

One set of five of them falls, hence the reason there are only ten.

Several hundred of you have read my presentation Step Aside HCAHPs; The Questions Hospital Executives Should Be Able To Answer.

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

One reader remarked that HCAHPs includes thirty-two questions, not the twenty-seven that were referenced in my slide deck.  I would like to be able to argue that as I was leaving CMS I dropped the stone tablet containing questions 28-32. I would also like to be able to fly.  Unfortunately, I can do neither.

That said, focusing on the number of questions in the survey obfuscates the point.  The number of questions CMS put forth has only a little to do with the issue of whether their questions constitute the Total Quality of a Person’s Encounter (TQE) with the hospital.

Image

As the picture above depicts, the effort to address patient experience only from the perspective of HCAHPs ignores much of what patients experience.  That same effort ignores all of what prospective patients, people who are trying to decide where to buy their healthcare, experience.

Let’s say your hospital treats five hundred patients a week, and thirty percent of them (150) return their surveys five months later.  The hospital may then initiate a program or two to try to raise its lowest scores.  Even if it is effective, it will not impact the experience of those who completed the survey, but it may increase slightly the scores of some future group of respondents.  The only people who will ever know are future patients.

People who will never know, and who don’t know anything about your HCAHPs scores are the people who were never your patients.  In know I am stating the obvious, but I do so because the potential revenue from that group, from the non-patients and the prospective patients, is probably greater than the revenues generated by the current patients.

Let’s also say that your hospital, the one that treats five hundred patients a week, also receives a thousand phone calls a week, and that three thousand people a week ‘visit’ the hospital via the internet.  Let’s also add another five hundred people a week who visit your patients.

That totals forty-five hundred people who experience the hospital in one form or another.  Were they satisfied?  Who knows?  They were not surveyed.  Nobody asked them what they liked. Nobody asked them if they found what they were looking for.  Did any of them decide to buy healthcare from your hospital?  Why or why not?  Did your internet presence meet their need; did the call center or the switchboard?

The lifetime value of a patient is estimated to be between $180,000 to $250,000.  The average number of people per household is three. So, for every patient you can attract and retain, plus their family members, their potential value to your hospital is $540,000 to $750,000.

Instead of Patient Experience Management, hospitals should be focused on Patient Equity Management. If a hospital lost four $2,000 computers in a week, it would learn quickly how not to lose a fifth. Hospitals lose patients and potential patients every day.  They do not know how many.  They do not know why. And, they do no know how to get them back.

Now watch what happens.  What if of the forty-five hundred people—the non-patients—you could get one percent of them (45) in any given week to decide to become your patient?  What might that amount to in terms of revenues? If you can get one percent a week, over a year, 45 people become 2,340.  Twenty-three hundred and forty people multiplied by the lifetime value of a single person’s revenue is a really big number—about four hundred million—a number so big it is silly; multiplied by the value of their family members is too big for me to count.

Now there will be those who want to argue that my numbers are way off.  To you I suggest that you make them smaller, make them a lot smaller.  Even if I am off by a factor of a hundred, which I am not, that is a $4 million dollar annual increase.