Why Patients Lose Patience

Who is responsible for patient satisfaction?  The flaw of averages suggests that the buck does not stop somewhere.

Your amygdala’s been hijacked.

The bad thing about being a former mathematician in my case is that the emphasis is on the word former. Sometimes I’m convinced I’ve forgotten more than I ever learned—sort of like the concept of negative numbers. It’s funny how the mind works, or in my case goes on little vacations without telling me. This whole parabola thing came to me while I was running, and over the next few miles of my run I tried to reconstruct the formula for a parabola. No luck.

My mind shut that down and went off on something that at least sounded somewhat similar, parables. That got me to thinking, and all of a sudden I was focused on the parable of the lost sheep, the one where a sheep wanders off and the shepherd leaves his flock to go find the lost one, which brings us to where we are today.

Sheep and effort.  Let’s rewind for a second. Permit me to put the patient lifecycle into physics for librarian style language—get the patient, treat the patient, lose the patient.  These are the three basic boxes where providers focus resources. How do manage the patient lifecycle to our advantage? We have marketing and sales to get the patient, we have patient care to treat the patient.  Can anyone tell me the name of the group whose job it is to lose the patient?  Sorry, I should have said to not lose the patient.

Patient retention.  Can anyone in your hospital tell me what specific efforts are underway to get patients to return the next time they need care?  I hope it involves more than the marketing department erecting another billboard with a picture of the urologists.

Where do most providers spend the majority of their intellectual capital and investment dollars? Hint—watch their commercials. It’s to get the patient. Out comes the red carpet. They get escorted in with the white glove treatment. Once they’re in, the gloves come off, to everyone’s detriment. Nobody ever sees the red carpet again. A high percentage of a hospital’s marketing budget is to get the patients. Almost nothing is spent to retain exiting patients.

Existing patients versus exiting patients. Why patients lose patience. 

Winning hospitals roll out the red carpet when patients exit. They do this for two reasons. One, it may cause a patient to return. Two, it changes the conversation. Which conversation? The one your patient is about to have with the rest of the world. How does your hospital want that conversation to go?

What do you have to do to get the patient to come back the next time he needs treatment? What the next visit of a patient worth to your hospital?  What about the next five visits? There seem to be a lot of questions for which answers seem to be missing.


Dinner’s warm, it’s in the dog–Patient Expectations

ImageLet’s see what we can somehow tie this to patients; I couldn’t resist using the title. The phrase came from my friend’s wife. She’d said it to him after he and I came home late from work one night, he having forgotten his promise to call her if we were to be late. Apparently, she hadn’t forgotten his promise. We walked into the kitchen.  “Dinner’s warm—it’s in the dog.”  She walked out of the kitchen.  I think that’s one of the best lines I’ve ever heard.

He was one of my mentors. We spent a lot of time consulting on out-of-town engagements. I remember one time I took out my phone to call my wife when he grabbed me by the wrists and explained I shouldn’t do that. We had just finished working a 10 or 12 hour day of consulting and had stopped by a bar to grab a steak and beer. I remember there was loud music playing. When I inquired as to why I shouldn’t call he explained.

“When your wife is chasing three children around the house and trying to prepare dinner, she doesn’t want to hear music and laughter and clinking beer glasses. She needs to know that you are having as bad a night as she is. So call her from outside, and make it sound like tonight’s dinner would be something from a vending machine.”

“But it’s raining,” I whimpered. Indeed it was, but seeing the wisdom in his words I headed out and made my call.

So, back to the dinner and the dog, and the steak and the phone call. In reality, they are both the same thing. It all comes down to Expectations. In healthcare it comes down to patient expectations.

PEM can be a number of things; Patient experience management, Patient equity management, and Patient expectation management. In this instance, we are discussing the latter. A set of expectations existed in both scenarios. One could argue as to whether the expectations were realistic—and one did argue just that—only to learn that neither of our wives considered the realism of their expectations to be a critical success factor. In that respect, the two women about whom I write are a lot like patients, their expectations are set, and they will either be met or missed.

Each time expectations are missed, their expectation bar is lowered. Soon, the expectation bar is set so low it’s difficult to miss them, but miss them we do. What happens next? Patients leave. They leave and go somewhere they know will also fail to meet their expectations. However, they’d rather give their money to someone who may disappoint them than somebody who continued to disappoint them.

How Medical Dummies Can Improve Patient Satisfaction

At some point raising your HCAP score will do no more for your hospital than being able to calculate the next decimal place of pi.  The law of diminishing returns.

The CBS Sunday Morning program ran a piece on medical dummies used to train doctors in a variety of procedures and specialties.  Practicing on a dummy, students could learn how to perform spinal taps, drain knee fluid, administer anesthesia, and deliver a baby. Medical schools are also hiring actors to help doctors improve their bedside manner. 

These medical mannequins cost upwards of three hundred thousand dollars.  They can exhale CO2, have dilated pupils, and swollen tongues.  Hospitals invest millions of dollars to ensure that the treatment their patients receive is the absolute best.  Doctors and nurses spend thousands of hours ensuring that the treatment they provide their patients is the absolute best.

They do not do this just to improve the patient’s experience; they devote their resources and their time to get it right, as right as they can as often as they can. How does that devotion translate to how patients rate their hospital experience?

What do we know?

  • All procedures are as good as the doctors and nurses know how to make them
  • All patients undergo certain procedures
  • Most patients undergo an array of different procedures
  • Almost no patients undergo identical procedures in the identical order
  • Improving the efficacy of a single procedure is good for those patients having that procedure
  • That improved procedure only impacts a small percentage of the total patient population
  • Small improvements of discrete processes will not improve the total patient experience rating for the hospital

What else do we know? (for simplicity let us focus on in-patients)

  • All patients are scheduled, admitted, housed, fed, discharged and billed.
  • Improving any one of these areas will improve the satisfaction of all patients

The big unknown.

  • Why is nobody focusing on the things that will raise patient satisfaction across the board

The hospital business processes for scheduling, admitting, housekeeping, food service, discharging and billing affect each patient.  Has your hospital ever asked your patients what their expectations are of these processes? I have not come across one that has.  But for those hospitals that do not know what patients expect from these processes, I guarantee you that your patient’s satisfaction barometer is measured against the one other service they purchase that has scheduling, admitting, housekeeping, food service, discharging and billing—staying in a hotel.

But we are not a hotel.  Please, no whinging.  Because patients have spent hundreds of nights in a hotel, their expectations of scheduling, admitting, housekeeping, food service, discharging and billing are predetermined and fixed. Each of these processes, at least when compared to medical procedures are exceedingly simple and the most repeated processes in the hospital.

The chances of your hospital exceeding your patients’ predisposed expectations are slim.  The chances of underperforming are great.  If you have not worked hard at reinventing these processes, your call center, your CRM, and your patient portal in the last two years, your chances of satisfying anyone border on nil. If you are being honest, some of these processes have not changed since the hospital was built.

What do we know about the employees who deliver scheduling, admitting, housekeeping, food service, discharging and billing to your patients?  They are the lowest paid, lowest skilled, least educated, least trained, and lowest tenured people in your organization.

These same people, what they do, and how well they do it contributes greatly to how patients will rate their level of satisfaction with your hospital.  My guess is that what they do and how it is perceived probably accounts for at least fifty percent of how they rate your hospital.

Here is what I propose.  Back to the medical dummies and the actors.  Could they somehow be employed to improve patient satisfaction for scheduling, admitting, housekeeping, food service, discharging and billing?  Imagine having someone in your billing department trying to get a dummy to explain the wherefores of a forty-thousand dollar invoice and you will get a pretty clear picture of how the patient feels when they have a question about their bill.

Remember, a rising tide lifts all boats, and that is a good thing unless you happen to be the person tied to the pier.

Crowdsourcing–The Patient is in charge

You may want to grab a sandwich, this is a long read.

For the longest time it has occurred to me that most companies find themselves in a state of what I like to label Permanent Whitewater. As they careen through the rapids, it is anybody’s guess as to whether they will capsize.  And the philistines they have appointed as commissioners would be more appropriately described as Ommissioners, as they have omitted themselves from understanding the world and leading their charges.

Now, what does that have to do with anything?  Thanks for asking.

For those of you who can find California on the map, you will recall the great turnip boycott of the nineteen seventies—I know they boycotted grapes, but I like grapes and do not like turnip, so I choose to have my own protest.  Anyway, this boycott worked, and as a result, the working conditions for migrant workers improved albeit only modestly.

And here is the kicker.  An entire industry was brought to its knees.  That is not the surprising part.  The surprising part is that all of this change was brought about at a time when there were three television channels and when people actually subscribed to newspapers.

From where I sit, social media can be divided into two camps, those who have not slept since the launch of Google+, and the far larger camp of those who have not lost a minute of sleep.  Businesses, for the most part are well entrenched in the latter group.

Part of the reason why businesses are slow to adopt social media can be attributed to their lack of belief that social media matters or can impact their business one way or the other.  And frankly, I think that has a lot to do with why our economy continues to rejoice in its malaise.

So, how to those of us in the first camp get those in the second camp to see the world our way, how do we get them to jump head-first into social media.  The answer is simple.  We need to create our own turnip debacle.

They say it cannot be done, so let us show them.  The one thing that would get companies to embrace social media quickly and unashamedly would be if there was one less company.

Companies, big ones, fat ones, firms that climb on rocks—feel free to finish the tune without my help have the following issues, they think they:

–       control their market

–       own their customers

–       are managing their customers

Companies are wrong about those three assumptions and the use of social media can and will prove this.  I would ask for a company to volunteer, but that would take too long.

If ABC, CBS, and NBC were able through their coverage of the grape boycott, bring about change to an entire industry, imagine with me what impact a global, committed bunch of savvy social media users could do to a single firm.

Here is what I propose.  Let us pick one firm.  The characteristics of this firm should be that it is well known and not well liked—this way if it self-destructs we can argue that we acted on behalf of a greater good.  It should also be a firm associated with technology, a firm that ought to at least be able to spell social media.  If I were asked which firm I would choose I would pick a firm in some aspect of telecommunications, say a firm like Comcast or Verizon—an easy target, a firm facing a customer experience war armed only with their CRM.

Now, the idea of our little social project will be to provide a heads-up to all of the other companies about the start date of the importance of social media.  Let’s tentatively agree on starting on the first of November unless there is a game on television I want to watch.

The goal of the project is to demonstrate that the bourgeois, the working class, with its harmless set of social media tools, can create affect enough of a disruption to an organization to make that organization sit up and take notice, or to make it disappear.

I am sure you remember the YouTube video of the Comcast technician that fell asleep on a customer’s couch.  It went viral, but Comcast did not, and that was simply a single posting by a single customer.  What would happen if the social media mavens decided to use the tools at their disposal and concentrate their efforts at or against a single firm?

Crowdsourcing 101.

I think the end result of such an effort would have a significant impact.  The impact could easily bring about more fundamental change about how firms use social media than was brought about by the grape boycott.

Sometimes something has to be sacrificed on behalf of the greater good.  Although a rising tide lifts all boats, it can ruin your day if your firm is the one chained to the pier.

What are your ideas?

When Patient Satisfaction is Personal

To paraphrase Oscar Wilde, ‘Consulting is the most unusual of the perversions’. 

Some say potato, some say po-tah-to; Dan Quayle, not often mistaken for one of Werner Von Braun’s rocket scientists, spells both versions with an ‘e’.

Customer/patient, patient/customer, impatient/customer—let’s just call him Ernest.  The importance of being Ernest.

The patient’s experience is not some abstract concept to be debated among the ‘six sigmaists’. Take today for example.  My father is lying on the floor with a heart rate of 147. He has had one heart attack.  At seven AM the ambulance takes him to the hospital, a hospital without a cath lab.  His enzyme markers are elevated, and they have to transfer him to a hospital that has the ability to treat him.  At 1 PM he starts to dress himself—he hasn’t seen a sole in five hours, he is leaving—like father like son.

It seems the hospital forgot to write a transfer order or to even check on him.

I hope they do not ask him to complete a patient satisfaction survey.

If you happen to read this he and I would both appreciate your prayers.

Patient Satisfaction–The Mathematics of Change

There are three people in the ER. One of them is a physician, one of them is an executive, and one of them is a consultant. They see a machine unplugged that is standing against a wall in the waiting room.

And the executive says, ‘Look, the technology in this hospital is not used.’ And the physician says, ‘No. There are machines in the hospital of which at least one is not used.’

And the consultant stood there in silence guessing neither of them really cared what he thought about the machine.

At least one. A mathematical term meaning one or more.

Some. A non mathematical term.

The term is commonly used in situations where existence can be established but it is not known how to determine the total number of solutions.  In our example, ‘E’ represents the unused machine and ‘C’ represents the unused consultant—the exceptionally bright among us will notice there is no ‘C’.  That is a problem on my end, but I digress.


How many things can be changed regarding the patient experience that would have a positive impact? At least one.

What would you change if you were not afraid of failing?


Is Patient Experience Management abi-normal?

I remember the first time I entered their home I was taken aback by the clutter.  Wet leaves and small branches were strewn across the floors and furniture. Black, Hefty trash bags stood against the walls filled with last year’s leaves. Dozens of bright orange buckets from Home Depot sat beneath the windows. The house always felt cold, very cold. After a while I learned to act normally around the clutter.

There came a time however when I simply had to ask, “Why all the buckets? What’s the deal with the leaves?”

“We try hard to keep the place neat,” she replied.

“Where does it all come from?” I asked.

“The open windows, the stuff blows right in.”

I looked at her somewhat askance. “I’m not sure I follow,” I replied as I began to feel uneasy.

“It’s not like we like living this way; the water, the cold, the mess. It costs a fortune to heat this place.  And, the constant bother of emptying the buckets, and the sweeping of the leaves.”

Trying to assume the role of thought leader I asked, “Why don’t you shut your windows? It seems like that would solve a lot of your problems.”

She looked at me like I had just tossed her cat in a blender.

When you see something abnormal often enough it becomes normal. Sort of like in the movie The Stepford Wives.  Sort of like Patient Experience Management (PEM). The normal has been subsumed by the abnormal, and in doing so is slowing devouring the resources of the hospital.

Are you kidding me? I wish. It’s much easier to see this as a consultant than it is if you are drinking the Kool Aid daily. When I talk to people about a statistic that indicates that 500 people called yesterday about their bill, and everyone looks calm and collected, it makes me feel like I must be the only one in the room who doesn’t get it—again with The Stepford Wives.

If I ask about the high call volume they always have an answer, the same answer.  “Billing calls are usually around 500 a day.”  They say that with a straight face as though they are waiting to see if I will drink the Kool Aid. It’s gotten to the point where no matter how bad things get, as long as they are consistently bad, they are not bad at all.

This is the mindset that enables the patient experience executive (I know you probably don’t have one—I am being facetious) to be fooled by his or her own metrics. When is someone going to understand that repeatedly having thousands of people calling to tell your organization you have a problem, means you have a problem?

It would probably take less than a week to pop something on your web site, and post a YouTube video explaining how to read the bill.  Next week, do the same thing and help patients understand how to file claims and disputes—granted, you may need more than a week for this one.


Without Control–the Patient Dialog

Remember when there were 200 firms in the Fortune 100?

How long ago was that? I think it was around the same time when people still thought you shouldn’t wear white after Labor Day. Time to drop-kick those white pumps to the back of the closet. What made me think of that bit of nonsense was a meeting I had recently with one of the sharpest people I’ve had the pleasure to meet professionally, and a classmate of mine from grad school. She happens to be the founder and president of one of the country’s go-to firms for dealing with business ethics. Having served as a board member for several publicly-traded firms, as well as chairing their audit committees, when the Andersen and Enron scandals hit she went looking for professionals who could help her help her firms. When she couldn’t find the help, she created it.

That conversation got me thinking and made me wonder why there were no longer 200 firms in the Fortune 100. Was it; is it, a matter of business ethics? How often do unethical practices come up when firms interact with their customers? A couple of takeaways from the meeting—for board members to be able to meet their obligation, they ought to do more than reply on the meeting book pulled together by the firm they serve. Simply relying on the book presumes ethical behavior, a presumption not always supported by fact—how much should one believe if the information is being provided by someone who purchased a $900 shower curtain?

What can they do? Due diligence is being reinvented, and the Social Network is leading the charge. One example is to go to Yahoo Chat to see what’s really being said about your organization. Other things I’ve done to obtain facts and opinions, things which particularly gauge how customers and employees feel about the firm include Google Reader, Facebook, Twitter, and YouTube, to name just a few. You don’t need patient focus groups to learn what’s being said, or to learn how good a job your hospital is doing. The patients already have a laser focus. In many instances the group lacking the focus is the healthcare provider.

Firms should focus on maintaining a strong Reputation Bank, one strong enough to be able to handle withdrawals, because you never know when there might be a run on the bank. Might be a good time to look at your own bank deposit slips.  Deposits can be made easily through the social media network.  You can’t stop patients from talking about you but you can shape what they say.

Patient Experience Management–What would Oprah do?

If you watch too much television your brain will fry. Sometimes I feel like mine is in a crepe pan that was left sitting on the stove too long. Two nights ago I’m watching Nova or some comparable show on PBS. The topic of the show was to outline all the events that took place that helped Einstein discover that the energy of an object is equal to its mass times the speed of light squared, better known as E=mc². It was presented to the audience at a level that might best be described as physics for librarians, which was exactly the level at which I needed to hear it. It’s physics at a level that is suitable for conversation at Starbucks or any blog such as this.

So here’s what I think I understood from the show. It tracked the developments of math and physics in the 100 years prior to Einstein’s discovery. The dénouement appeared to occur when Einstein and his fiancée were riding in the bow of the small boat. Apparently, he was leaning over the side of the boat and noticed that the waves generated by the front of the boat moved at the same speed as the boat. He then noted that fact only held true for those persons in the boat, who were in fact, traveling at the same rate of speed. However for those persons watching from the shore, that same wave was not only moving slower than the boat it got further behind over time. Some other things occurred, yada, yada, yada, and there you have it. Clearly, the details are in the yada, yadas.

So here’s what happens when you watch too much television. As I’m running this morning somehow my mind takes pieces from that show and staples them together to yield the following. Let’s go back to the equation E=mc². For purposes of this discussion I’ll redefine the variables, so that:

E = the percentage of Patient Complaints/Inquiries.
m = Patient in-bound calls.
c = number of Patients

If this were true–this is an illustration, not an axiom–the number of complaints to a healthcare provider is equal to the number of in-bound calls times the square of the number of patients. So as the number of calls increases the number of complaints/questions increases and as the number of patients increases the number of complaints increases exponentially. Of course this is made up, but there appears to be a grain of truth to it. I think we can agree that a reasonable goal for a healthcare provider is to decrease the number of complaints and inquiries and to shift a hefty percentage of inquiries to some form of internet self-service vehicle.

I think sometimes the way providers assess the issue of Patient Experience Management  (PEM) is by looking at how much money is spent trying to solve the problem. Some think that if one provider has three times as many people handling calls as another provider that the provider with three times as many people must be more interested in taking care of the their patients, and might even be better at PEM.  I don’t support that belief. I think it can be demonstrated that the provider with the most Patient Service Representatives, and the most toys deployed probably has the most problems with their patients. I don’t think it’s a chicken and egg argument. If expenditures to handle patient complaints and questions increase year after year and resources are deployed continuously to solve the same types of problems, I think it’s a sign that the provider and its patients are growing more and more dysfunctional.

How does this tie to Einstein and his boat? Perhaps the Einsteins are those who work with the provider; those who are moving at the same speed, those in lockstep. From their vantage point, the waves and the boat, like the provider and its patients, are all moving forward at the same speed. Perhaps only the people standing along the shore are able to see what is actually occurring; the waves distance themselves from the boat in much the same way that the patients distance themselves from the provider.

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.