The Downside of Patient Experience

The Enchanted Forest was my first employer. My job was to direct cars to available parking, affix bumper stickers to those cars, and pick up the discarded Pampers—I lasted less than a day.

I mention that because today I had the pleasure of laboring through security at Philadelphia International Airport. Cattle awaiting slaughter in Chicago’s stockyards have a better experience.  Given the choice of being a TSA agent or picking up Pampers at the Enchanted Forest I’ll take the Pampers.  Lest we forget, all Americans should be forced to go through airport security once a year just to remember what those clowns did to us on 9-11.

I am flying USAIR; not by choice.  One of my fellow alums, our school’s poster child for success, is the CEO of USAIR.  I bet he flies Southwest, or maybe he does the John Madden thing and rides in his own bus whenever he has to travel.

Remember the old airline slogans, “We love to fly and it shows,” and “Fly the friendly skies of United,” and Delta’s “We’re ready to fly when you are”?  Today the universal slogan of the airline industry is, “We don’t like flying any more than you do, but hey, it’s a job.  We are no worse than the other airline.”  There is no pretense about competing on customer experience.  Far from it.

Airlines no longer even pretend to compete on price. It is almost as though they compete with one another to see which airline can come up with the most irritating surcharges.  Should we be forced to make an emergency water landing—as though there is anything other than an emergency water landing—your seat cushions may be used as flotation devices.  There is a five dollar non-refundable charge for those who may wish to use their seat cushions to save themselves and their loved ones.  A flight attendant will be passing through the aisle to collect payment and unlock your cushion.

To board the plane I had to pass between two closely aligned, six-foot, vertical, buttered rollers that were designed to lubricate both sides of each passenger to enable passengers to squeeze into the aircraft’s Barbie Doll seats.  As I am seated in an exit row I decide to take advantage of an on-the-spot micro-business opportunity.  I stand and announce to my fellow passengers, “Should we be forced to make any type of emergency landing you may wish to exit the plane.  There is a five dollar non-refundable charge for those who may wish to exit through my window exit.  I will be passing through the aisle shortly to collect payment.

The marketing campaign for the airline industry seems as though it was pulled almost word for word from the Les Misérables song, Master of the House.  “It doesn’t cost me to be nice, nothing gets you nothing, everything has got a little price. Master of the house, keeper of the zoo, ready to relieve them of a sous or two…charge ‘em for the lice, extra for the mice, two percent for looking in the mirror twice.”  Essentially their customer retention plan is we can do whatever we want to you…if you don’t like it you can always walk.  “Two percent for looking in the mirror twice.”

Customer experience.  Patient experience.  Driving to the airport this morning NPR ran an advertisement from a Philadelphia hospital that was touting its hip and knee replacement offering.  You may not know this, but hospitals have a department that specializes in business development—I kid you not.  Highly trained individuals, MBAs—most likely all of the airline CEO positions were taken, toil day after day trying to figure out the answer to the question that has plagued mankind since the invention of the Band-Aid, ‘How do we get sick people to come to us’?  Give us your tired, your poor, your huddled masses…healthcare’s business development strategy could be dubbed the Statue of Liberty strategy. 

Sometimes the business development people get together with the marketing people—it is like a Mensa meeting minus the mense—no need to look it up; I was just going for the alliteration.  I think this is how the billboard strategy of attracting patients came into being.  You know the one about which I am writing.  A mile or so from every hospital is a mammoth billboard depicting a photo of the hospital’s urologists—substitute your favorite specialty—all of whom are smiling.  I think the idea behind the billboard is to entice you to use their services should you happen to be passing a kidney stone as you are driving by.  (I read that in California the photo of the urologists has been replaced with a photo of the nip-&-tuck squad.)

What many hospitals seem to have failed to notice, or to have made operational, is that prospective patients choose their providers.  This has been going on for well more than a decade.  I know this because when I had my heart attack the ambulance driver determined where I was to be treated, a hospital fifteen minutes from my house.  For the last ten years I have chosen to travel more than an hour each way to the cardiologist I selected.  The original hospital, which has lost tens of thousands of dollars by not retaining me, does not even know if I am alive.  They never called to find out.  By the way, they have a lot of billboards.

Patient choice is undermining a lot of hospitals’ revenues.  As much as the healthcare industry would like us to believe that people choose their provider only based on specializations and mortality rates, other factors come into play.  One of those other factors, perhaps the biggest factor, is patient experience and their satisfaction with that experience.

Cancer Treatment Centers of America seem to have figured that out.  Their advertisements appeal to our base Freudianish needs, that the individual is special and wants to be treated as such.  CTCA does not advertise that you will not die if they treat you.  Their advertisements and their testimonials focus on the fact that their patients are treated like family. 

Essentially CTCA  have figured out that it is good business to approach cancer patients as smart customers.  CTCA cannot campaign on the fact that their patients don’t die.  Unfortunately cancer patients die, so that dog don’t hunt.  They cannot campaign on the fact that their treatment doesn’t make you nauseous, but as I also know from personal experience, chemo is awful, so that dog don’t hunt either.  So CTCA claimed the unclaimed ground, the ground over which none of their competitors are fighting; patient experience.

The CTCA’s phone lines are open 24 x 7, or you can reach them through a chat line to let them convince you about their integrated, specialized plan to treat you.  (They do not however have an iPad app which means they just lost points in the patient experience bonus round.)

Their patients travel across states at great personal expense.  Their patients are willing to pay more for even the possibility of a better experience.

I’ll close with this.  Almost every hospital has at least one MRI.  Each MRI probably delivers the same high quality images.  Each hospital probably has equally competent radiologists to read the images.  What then is your hospital’s competitive advantage?  Perhaps it is time to be able to answer that question.  The downside of competing on patient experience is that to do so you had better be pretty good at it.

Patient Satisfaction: Still buying Data and Coaching, Why?

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

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

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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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?

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.

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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?