Dying to Improve Patient Experience?

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?

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

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.

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

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.

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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

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?