patient experience management

Patient Satisfaction: Still buying Data and Coaching, Why?

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Think about the answer to this question, how many nights have you spent in a hotel in the last decade?  For most of us the answer is more than one hundred.  How many nights have you spent in a hospital in the last decade?  For most of us the answer is probably between none and ten.  So then, when you go somewhere to spend the night and have your meals delivered, from which organization do your expectations about being satisfied most likely come?

Patient, customer. Hospital, hotel. Tomato, ta-mah-tow.  For those who want to argue that there are no similarities feel free to continue to do so.  For the rest of us let us look at how to improve patient satisfaction.

A few days ago I spoke with a hospital CEO about his efforts to improve the patient experience and about patient satisfaction.  He said that for years his hospital has spent a lot of money buying all sorts of data about their patients’ experiences.  The problem he said is that the company providing the data never did anything more than sell them the data.  So they kept getting all of this data but never saw any improvement in their patients’ experience that could be tied to the data they purchased.

That hospital has also hired coaches in the belief that this would help improve the experience.  The results were the same.

I asked him why he kept spending money when the expenditures failed to deliver the desired result.  He replied that the two things he knew he could do that would yield the greatest and most immediate increase in patient satisfaction would be to increase the number of parking spaces and to improve the food service.  Did he learn that from the survey data or from the coaching?  Nope.  He learned that from his patients’ family and friends.

Four rules worth remembering:

  1. Experience and satisfaction are related but they are not the same.
  2. Every patient has an experience but the experience does not always result in a satisfied patient.
  3. Patient satisfaction cannot be improved without knowing a patient’s expectations.
  4. Purchasing data and paying for coaching do not change rules 1-3.

Having thousands of data points comparing how your hospital is performing against other hospitals gives you a report card; it does not improve either the patient’s or patients’ experience. Coaching employees probably will not improve patient experience.

It is not the employees that need fixing.  Broken, outdated processes result in dissatisfied patients.

Patients have multiple points of contact with the hospital; before they are admitted, while they are in the hospital, and when they go home.  If you can answer the following questions you have a basis for improving patient satisfaction.

  • Which points of contact have the greatest impact on patient satisfaction?
  • When did anyone last ask patients to define their expectations?
  • Which points of contact affect most of your patients?
  • Which points of contact are frequented most by your patients?
  • What are the consequences of not knowing these answers?

The answers to these questions do not require purchasing data, nor do they require coaching.

Two highly frequented points of contact are your website and your call center.  Go to your web site and try to complete a simple task—schedule an appointment, or try to understand your bill—taks that might be done by a patient or by a patient’s family member.  Could you do it?  Were you satisfied?

Now dial the call center and ask the person who answers the phone a question about Medicaid or Medicare billing.  Could that person give you the correct answer?  Could the person they transferred you to give you the correct answer?  Did the recorded voice telling you to call back between the hours of eight and five give you the correct answer?  Were you satisfied?

If you were not satisfied, why would you expect your patients to be satisfied?  Satisfaction has everything to do about processes and customer service.  Data and smiles do nothing to improve broken processes and poor customer service.

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Why your Website is Killing Patient Satisfaction

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Hospitals probably have more than one hundred points of contact with each patient.  These points of contact (POCs) begin before the patient is admitted and continue after the patient has been discharged.

The first contact may come by a visit to one of the hospital’s clinics, a 3 A.M. call to a primary care physician, or browsing the hospital’s website.

Yesterday I assessed whether the website of a large hospital group was functional or whether it was just a website window-dressed to look like a customer portal. I assess functionality based on whether I was able to accomplish what I set out to accomplish.

I counted dozens of different phone numbers to call. Along with the list of numbers were links for physician and employee portals, links to the board, a link for donors, wellness, specialties, medical professionals, and dozens more, all on the front page. 

There was even a link, albeit not a portal for patients—a rather important link since the number of visits by patients and prospective patients probably greatly exceeds the combined number of visits by all other visitors to the site.  Unfortunately the patient link was imbedded with six other equally weighted links.

I clicked the patient link and was greeted by two-dozen new links, each displayed as being of equal importance.  There were links for patients to use before coming to the hospital and links for them to use once they were home.  Points of contact with your hospital.  Points of satisfaction or dissatisfaction. 

I clicked some more.  Schedule an appointment.  There are actually two links for scheduling an appointment.  The first link gave me a phone number I could call M-F between 8 and 5:30 P.M.  What number do I call at 6 PM I wondered?  I tried the second link; it took me to the same place. Could I schedule an appointment online or through a mobile device?

What did I learn? There are 168 hours in a week.  Their scheduling service operates for 47.5 hours a week, 28% of the week’s hours. If I dialed that number after hours would I get a recording telling me how important my call was?  If my goal was to schedule an appointment using their website, or to schedule an appointment at any time on any device not only did the hospital not meet my expectation, it did not even offer me an alternative. A dead-end.

If it costs the hospital thirty dollars to schedule an appointment by phone and nothing to schedule an appointment online, why not complete the task correctly, the first time, and for zero cost?

I next looked at what I could do when I was home, more POCs, more chances to be satisfied or dissatisfied. 

Manage my medical records. Using the website I was able to print and mail, two very non-electronic processes, a request to have my records printed and mailed to me.  There was no way to submit my request using their website.  If I did not own a printer or did not have access to a printer my expectation was not met, and was I not offered an alternative.  Some people, a whole lot of people, actually like to complete tasks using a tablet or smart phone. Another dead-end.

Let’s try billing. For Medicaid patients there are two numbers to call for help understanding your bill. That means understanding Medicaid bills is a nontrivial exercise.  That tells me that if I asked the same Medicaid billing question of three different people I might expect to get three different answers.  Why not design the sight so that it provides one right answer to whatever question is asked?  Why not include an online chat feature? Why not create a link to a YouTube video, produced by the hospital that explains Medicaid billing?

Medicare.  No link to prequalifying, not even a phone number for questions.

How to pay your bill.  Perhaps the most difficult and least desirous task a patient must do. There is no link explaining the various components of the bill, and nowhere on the site is a copy of a sample bill explaining or highlighting the various sections of the bill.

There is also no link to understand how to file a dispute or a claim with a payer.  Maybe it is not possible to do this for every payer, but using the 80:20 rule there must be ways to help the majority of patients understand what they are up against rather than having them face down the evil empires on their own.

Patients come to the hospital’s website with expectations.  Patient satisfaction is repeatedly won or lost at your hospital’s website and on the phones.  POCs.  Having a tool that proposes to help patients with their bills that not only does not help them but that adds to their frustration will crush patient satisfaction.

Hospitals want patients to pay their bills and to pay them on time.  Patients who do not understand their bill will not pay more completely, nor will they pay faster.

The next time you look at your hospital’s website ask yourself how different it would look had someone asked a patient how it should function.

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Why Patients Lose Patience

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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.

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

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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

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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.

When Patient Satisfaction is Personal

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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.

Just What is Patient Equity Management?

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My presentation ‘Patient Equity Management” the next step up on Patient Experience Managementow.ly/juObm

 

 

Patient Satisfaction–The Mathematics of Change

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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.

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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?

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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.

 

Why HCAP Scores Do Not Work

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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