patients

How Can Reinventing Patient Experience Decrease Readmissions?

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As I was going up the stair, I met a man who wasn’t there.

Then I read an article espousing the ROI of EHR.  I leave it to you to decide if these two activities are one in the same.

I also read an article on reducing readmissions in this month’s HealthLeaders, Readmissions: The Big Picture.  Perhaps it is because my synapses do not work the way they were intended to work, but the first thing that came to mind for me was How could Patient Experience be reinvented to help contribute to the goal of reducing readmissions?  Could deliberately coloring outside of the lines help to solve a real problem?

It absolutely can.  One reason patients readmit is because of their failure to comply with their discharge instructions.  They do not do what they are supposed to do, they do not do it with the frequency with which they are supposed to do it, or they do not understand what to do, who to contact, how to contact them or when when something goes akimbo.  And worst of all, nobody at the hospital knows anything about these failures until the patient is readmitted.

Many of us have been discharged.  I remember the discharge process as the only thing standing between me and the front door.  I would have nodded to anyone and signed anything to be home and to have the hospitalization behind me.  I would read the fine print once I was paroled, once I had a real television remote in my hand, not some off-white three-channel device that was tethered to the hospital bed.  Is it possible that more than a handful of patients feel this way?

Since you cannot give patients a test to confirm they understand their instructions prior to discharging them, and you have no control of patients once they leave, is the situation hopeless?

Patient experience continues once patients are discharged.  Or it could.  Post discharge, most patient experiences—and family experiences—consist of calling the hospital for a variety of reasons; understanding discharge instructions, scheduling a follow-up appointment, scheduling a lab, understanding a bill, filing a claim—reasons very similar to those encountered by patients before they are admitted.  Unfortunately, the people being called may not know the right answer to any of these questions.  Unfortunately, the line may be busy; it may be after hours, or during the lunch break.  Access 8 a.m. until 6 p.m.

They call the hospital.  How well did that work?  If the answer is not well, they may be on their way to having a very poor experience.  If it concerns their discharge instructions they may be on their way to being readmitted.

Here’s how we can tie reducing readmissions to patient experience.  It is not complex, it does not require and MD or a PhD, and it is not really all that innovative unless innovation means looking at solving the problem in a way that differs from the way solving problems is normally looked at.

It is all about access, two-way access.  Two-way access between the hospital and the patient.  Digital and mobile access.  Twenty-four by seven.  I know you do not do it this way, and the natural reaction to this idea is that some of you will have a long list of reasons why this cannot be done or why it will never work at your hospital.  It won’t work for people who do not want it to work, or who may not have the skills. One invalid excuse for it not working is not because it cannot be done.  It can, someone just has to tell someone to make it happen.

Let us take a non-natural reaction, just for a minute.  I envision the following—this is not exhaustive, it does not come from hours of research.  It is just a back-of-the-napkin idea that I would like your opinion as to whether it is worth another napkin or two.

What if the complete discharge summary, and everything patients needed to do, could be available to the patient and the primary care provider in real-time, at the time of discharge?  What if the patient’s behavior and compliance could be recorded, tracked, and reported?  Online access.  Perhaps on an iPad type of device.  Let’s use me as an example, me, the guy who was in too big of a hurry to get discharged to pay attention to my instructions.

Now that I am home I read the instructions.  I register on the website using some form of secure ID that pulls up what I need.  I read about my medications—what they are for, when I have to take them, possible side effects.  I discover that I can track my recovery progress on the site, enter when I take my meds, record when I may have exercised or gone to therapy, perhaps enter what I ate, my blood pressure, and weight. 

Maybe my wife logs in and helps me schedule an appointment, therapy, or a lab. If I schedule a lab the site tells me my instructions prior to having the lab work done, and I provide an electronic signature to confirm my understanding of those instructions.

If I have questions I use the online chat function, or I submit a question that will be replied to within an hour.

My primary care provider can access my progress.

This is certainly not an exhaustive list of tasks, and it deserves more consideration than the twenty minutes it took to write this post.  However, if you pair the idea of decreasing admissions and increasing access, and do so using user-centered design to create an intuitive user experience you may be surprised by the results.

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

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

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

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

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

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

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

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

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

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

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

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

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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.