Patient Experience: A Whinging Rebuttal to the Notion that Patients are not Customers

I really like the fact that people comment and disagree with me.  That is how I learn from them.  However, if you want to have a battle of whits, it is best not to come to the fight unarmed. Below is my third response to an individual who commented repeatedly, and concluded that I am a liability. The post that seemed to have attracted his ire can be found here

The surgical gloves are off, and since I’m the guy paying for this pulpit, away we go.  I would love to read your thoughts…no, really.

If you built a hospital in the woods and nobody came would it make a difference?  It would because you would not have any patients.  Let me try this again in English, even as you write that I am a liability.

Retention is nothing like re-admission.  A retained patient or customer is someone who will come back to the business the next time they need to make a purchase.  Retention is when a gall bladder patient had such a positive experience that they come back for a bad knee, for an endoscopy, blood work—anything the hospital sells that someone needs.

Using my calculations, a person is worth between $180,000 to $250,000 over twenty five years.  Managed correctly, a family of four could be worth up to a million dollars in future revenues.  That is an asset any hospital CFO would fight for.  Those numbers work whether someone was a patient, is a patient, or may be a patient.  Care for a lifetime equates to a lifetime value of a patient.

If you do not retain me as a patient, what does it cost to find another person to take my spot?  The rule of thumb across industries is that it costs ten times as much to acquire a new customer as it does to retain one.

I recently spoke with three people with PhDs in healthcare economics.  I asked them if they had seen any data about what it cost to acquire a single patient.  They had not.  Business development is one of healthcare’s black holes.

If as you wrote, these people—the ones who are not considered patients simply because they were discharged or have never been treated by the hospital—were worth nothing, as in not an asset, then I am sure you will agree that we should close the marketing department and the business development department, take down the billboards, and quit advertising on NPR.  That would free up a lot of parking spaces.

As difficult as it is to make money in healthcare, one must ask why hospitals market themselves.  Are they simply altruists?  Or, are they trying to attract patients?  If they are trying to attract patients there must be a reason.  I think it is because patients are worth something, they have a value.  Patients pay for services—we all know that there are many, many hospitals who given a choice would like to have a higher percentage of their patients who can elect to have costly procedures—high earners.  This group of patients in effect underwrites the other group of patients that cannot afford to purchase as much healthcare.

As to why a hospital should keep up with a patient after the patient is discharged, the list is too long to complete.  However, again using me as an example, my hospital got four days of revenues for treating me for the heart attack.  Penn Medicine on the other hand has received eleven years of revenues for all of the follow up related to my heart disease.  Penn Medicine, because of my positive experience, treated me and my family for other things (none of which were readmissions.)

If hospitals do not treat people as customers as well as they treat them as patients, they will have neither.  The strategy you suggest is no different than telling the hospital that it must replace its entire base of patients every year if it is to earn as much as it did this year.

The Democratization of Patient Satisfaction

So, how can you tell how the hospital’s patient experience improvement effort is progressing?  Perhaps this is one way to tell.

A man left his cat with his brother while he went on vacation for a week. When he came back, he called his brother to see when he could pick the cat up. The brother hesitated, and then said, “I’m so sorry, but while you were away, the cat died.”

The man was very upset and replied, “You know, you could have broken the news to me better than that. When I called today, you could have said the cat was on the roof and wouldn’t come down. Then when I called the next day, you could have said that he had fallen off and the vet was working on patching him up. Then when I called the third day, you could have said the cat had passed away.”

The brother thought about it and apologized.

“So how’s Mom?” asked the man.

“She’s on the roof and won’t come down.”

If you ask someone how the patient experience improvement effort is going and she responds by saying, “The project leader is on the roof and won’t come down,” it may be time to get a new leader.

There are more than 120,000 URLs returned when searching “’Why do patients choose’ hospital”.  Based on what I read, the URLs all take the reader to something written by the hospital.

Sixty percent of people say they use the internet to make a healthcare decision.  Sixteen percent of hospitals use social media.  Eighty-one percent of prospective patients stated that a hospital with a strong social media presence is likely to be more cutting edge—you do the math.

Whether your hospital has a strong social media presence may be less relevant because your prospective patients certainly do.  So what does that knowledge do to your organization’s patient experience strategy?   Do you double or triple you social media output?  Does your one or two person internet department try to out-social-media thousands of prospective patients, Twittering away, and constantly posting to Facebook?  Trying to catch up is like trying to walk across a room, and with each successive step cutting the remaining distance in half—you never get to the other side.

The social media “experts” would tell you that is exactly what you need to be doing—more is better.  I think the experts are wrong.

If the experts are wrong, what is the right approach?  The internet is a powerful touchpoint for both patients and prospective patients.  The internet is a large component of patient satisfaction, patient experience, and patient choice.

Rather than going wide and shallow with social media or social-CRM think about a narrower mobile digital strategy that goes deep. For example, think about your hospital’s website.  For starters, what you have is probably just that, just a website. 

There are dozens and dozens of reasons a patient or prospect would go to your site.  A high percentage of them go there because they do not want to try to accomplish something by dialing any of the hospital’s multiple phone numbers.  When they go to the website if it does not entice them to stay on the site, bookmark it, or make it their homepage, the website might as well not exist.

Your website is where purchasing decisions are made and lost by prospective patients, and where satisfaction is raised or lowered for patients.  If a patient cannot accomplish the task they set out to do in an intuitive and user-friendly way, their satisfaction with your entire organization just dropped.

Many more people go to your website than go through the front door of your hospital.  The good news is that you control the user experience of someone on your site.  The bad news is that most organizations are controlling it in a way that gives users a poor experience.  The list of things users cannot do on your website is much longer than the list of things they can do.

Having a tab that reads ‘schedule a visit’ is worth nothing unless the patient was able to schedule a visit, in fact, it probably kills satisfaction.  Having a tab that reads ‘get your health records’ that requires someone to download a PDF, print it, and mail it is equally bad for patient satisfaction.

What should your website be?  At a minimum it should be some combination of a patient portal and a knowledge management system.  It should also be your billing department, your scheduling department, admissions, discharge, housekeeping, food services, support groups, and education services.

Your website should offer every service your hospital offers with the possible exception of a hip replacement—a 24 by 7 virtual hospital minus patient care.  Two-way.  And mobile.  Available on any device at any time.

If you want to interact with your community, patients and non-patients, you need to go to where they are.  And where they are is online.  It is not good if someone with heart disease can watch an angiogram on YouTube or on a competitor’s website and on your website they cannot even find a meaningful cardiology link.  Online patient support groups at the best hospitals provide a real-time referral group—can your patients do that on your site or do they have to go to someone else’s?

Patients are democratizing information. If the information provided by your organization is asymmetrical, it has some catching up to do.

Patient satisfaction—a remarkable experience for every patient every time; in the hospital, on the web, and on the phone.


Could a Zagat-type Patient Satisfaction Rating Work?


The woman next to me on the plane was eating a croissant.  I asked her if she could hear Paris if she held it to her ear.  Maybe you had to be there.

The rest of this piece will make more sense if you have Wagner’s Valkyrie from the scene in Apocalypse Now playing in the background.  This weekend we did a once in a lifetime family activity.  Paintball.  It was once in a lifetime because I knew we would never want to do it twice.  Wearing our best WASP outfits, which made us look more suited for viewing the US Open than traipsing around in the woods, we drove two hours to a remote spot in the Poconos where we stumbled upon what looked like an interracial survivalist training camp; Pennsylvania’s version of Ruby Ridge.

The car next to ours had a bumper sticker printed with the words, “Honk if you are Amish.”  I told my son that I was surprised the Amish would play paintball.  He told me that it was meant to be funny since the Amish did not own cars.  Anyway.

Hundreds of people in the non-erudite crowd were dressed the way I wished I could have dressed when I played army at the age of eight though none of these people had been eight for quite some time.  Those whose arms were exposed displayed militaristic tattoos—while the men were wearing long-sleeved shirts.  Some of the GI Joes were dressed like SWAT, the rest were kitted head to toe in camouflage.  Several wore ghillie suits.  There were head and shoulder-mounted video cameras, and a few of the survivalists had wireless communication devices.  Most wore backpacks and other paraphernalia that would have made SEALs envious.

We passed one group as they were retrieving their rifles from the trunk of their car. Their gear copied the design of Uzis and AK-47s.  I started wondering what someone from a nearby town would have thought had a few of them walked into a liquor store to buy beer, imagining the clerk handing over the tens and twenties and then fleeing out the back door.

Our ammo belts each held over a thousand paint balls.  We gathered our guns and put on our face shields, the visors of which made us look like oversized ants, and headed into the woods to one of the seven hundred acre’s fifty laid out battle areas.  Our group of eighteen was divided half.  Being the only one with the math degree, I explained each team should have about nine players.

Fallujah awaited.

My two sons and I were on the team opposite my wife and daughter.  I smelled payback and before the referee blew his whistle signaling the start of the game I began a flanking maneuver to what would have been the field’s starboard side had we been on a ship.  Passing through a copse of birch, I came upon a pile of logs.  Within five minutes I had taken out three of their nine players.

Did I mention it then started pouring?  Now we were wet WASPs and my son appeared to be doing the backstroke.

One thing I learned quickly is that breathing heavily into your face shield during a downpour makes your vision about as clear as looking through your glass shower door twenty minutes into your shower.  The fog of war?  In the shower not being able to see is merely an inconvenience whereas in the woods people were shooting at and hitting me.

My vision was totally obscured.  I could see shapes and vestiges of light and dark.  Unfortunately I could not see the vestiges that were shooting me.  With a fogged visor, standing alone, and holding my gun I resembled a blindfolded person at a birthday party swinging an object at a moving piñata, only this time I was the piñata.

Did I mention that the paintballs leave the barrel of the gun traveling at one hundred and ninety miles an hour?  Through painful personal research I learned that exposed skin can instantaneously drop the paintball’s speed to zero. 

I think sometimes executives find themselves shrouded by the fog of war, unable to see what is right in front of them.  When was the last time people on the uppermost floors in the hospital sat down with a patient and spoke to them about their impression of the hospital?  It has probably been a while.

If it were possible to rate patient experience and patient satisfaction for your hospital using the prestigious Michelin and consumer-loved Zagat restaurant ratings, how do you think your hospital would score?

Michelin uses secret inspectors to rate restaurants—think CMS, HCAHPs, and patient satisfaction because patients are asked to completed surveys—customers have no say in the ratings.  Restaurants can be awarded one, two, or three stars.  Only about two thousand restaurants in the world have received a Michelin star.

Zagat ratings are formulated by people who ate in the restaurant—think patients and patient satisfaction.  Customers are not asked to rate the establishment; they do so on their own; customer driven.  Think also YouTube, Twitter, Facebook, and blogs.

What would happen to the flow of first-time and returning patients at your hospital if patients had an independent, online, patient-driven rating site?  Now before you bust a blood vessel, I am not suggesting that this approach could be used to rate physicians or treatment.  I do think there may be merit in using it to rate patient touchpoints of nonclinical things.  What sorts of things?  How about things like:

  • The usefulness of the website and the call center
  • Parking
  • Food service
  • Admissions
  • The clarity of the bill
  • Social media aides
  • Appearance
  • Scheduling

One CEO told me that the two things he could do that would have the greatest impact on patient satisfaction were expanding the parking lot and improving the food service.  Might be a good way to add another rating star to the hospital’s website banner.

Why Satisfying Patients is Dysfunctional

Technology creates trust among people who have never met.  Individuals, grouped via the web into “smart mobs” are sharing and collaborating in ways hospitals cannot. The individual has transformed from being a passive consumer into one having the collective intelligence of a mob of educated collaborators.

And guess what?  Hospitals are still marketing to and doing business development with individuals.  How well is that working?  These groups of patients and prospective patients are interacting en-mass while the hospital continues investing its resources erecting billboards and telemarketing prospective patients using Salesforce.

Using 1980’s technology hospitals are chumming the universe of potential patients armed with less information than they could find about a person using Google.  Their quarry, on the other hand, is armed by having access to information that represents the collective intelligence of every member of its smart mob.  The smart mob has developed a metasystem of information and opinions about organizations and they will use that metasystem to help them decide whether they will purchase services from your organization.

It is not a fair fight. A battle of wits in which one side is unarmed.

Disrupting the business model and changing the way you do something are not the same.  Motion is not movement.  Lean in not disruptive.  If your organization can be counted among the fans of the lean sigmaists and you want to be really lean all you have to do is turn of the lights and lock the doors; you can’t get much leaner than that.

After a while there will be nothing left to cut or change except to change what you do.  Building capacity for every sub-specialty is not disruptive, it is dysfunctional.  Having more MRIs in your facility than there are in Manitoba is the opposite of lean.  Isn’t it nonsensical to be lean in a few areas and obese in others?  Offering the same services as every other hospital in the area is not disruptive, it is duplicative.  It simply divides the revenue pie for any given procedure into smaller slices.

Hospitals know what they charge, not what their procedures cost.  They can’t pull a P&L per patient, or per procedure.  Healthcare does not know the ROI or NPV of retaining a patient or what it costs to acquire a patient.  If it did, it would invest more resources trying to retain patients, obtain referrals, and win-back former patients. 

Can hospitals make a sound financial argument for having a business development executive instead of a patient retention executive?  It costs ten times more to acquire a new patient than to retain one.

Is having a business development group in a hospital disruptive or is it dysfunctional?  Does it add value?

I ran the question through my head and discovered the following.  In the last decade my immediate family has purchased some form of healthcare at eight different hospitals within twenty-five miles of our home.  Each time we purchased healthcare from a hospital the other seven hospitals never knew we were looking to make a purchase.

To be more specific, once a year I take a cardiac stress test at one of the hospitals.  A cardiologist is present during the test.  Not once in the last ten years has anyone from the hospital told me about their cardiology services or invited me to tour their facility.  But they have a business development group and they advertise their cardiology practice.

Every hospital’s business development group is competing by pitching the same services as every other hospital in their market, and they are pitching those services to the same people as the other hospitals’ business development groups.  Don’t believe me?  Ask your CFO how much revenue the urology billboard generated or whether the business development group covered its costs.

Why are none of the hospitals competing on having the best patient experience?  If a hospital sells customer experience and customer satisfaction it will retain patients, get referrals, and win-back former patients.

Selling customer satisfaction in a market where none of your competitors is selling it is disruptive.  Disruption of an antiquated approach is a good thing.  How can your hospital disrupt its approach to improving patient experience?  Doing the same thing this year that you did last year is not disruptive it is dysfunctional.

If you need a vision statement for patient satisfaction how about using the phrase, A remarkable experience for every patient every time?  It sounds a lot better than ‘a satisfied experience.’  Simply being satisfied isn’t saying much.  If someone tells you that the place they had dinner last night was satisfying it probably doesn’t make you want to rush out and eat there. 

With so many hospitals competing for the same patient perhaps simply satisfying patients is dysfunctional.  The disruptive approach would be to plan to deliver a remarkable experience for every patient every time.


The Wildebeest Postulate of Patient Satisfaction

The Kalahari; vast, silent, deadly. The end of the rainy season, the middayImage heat surpasses a hundred and twenty. One of the varieties of waterfowl, most notably the flame red flamingo that nested in the great salt pans in Botswana, has begun its annual migration. In the muck of one of the fresh-water pools that had almost completely evaporated, writhes a squirming black mass of underdeveloped tadpoles. A lone Baobab tree pokes skyward from the middle of the barren savanna. In its shade, standing shoulder to shoulder and facing out, a herd of wildebeest surveys the landscape for predators.  Sir David Attenborough and PBS can’t be far away.

Some things never change. I make my way across the freshly laid macadam to meet the school bus. Fifty feet in front of me is a young silver maple tree, the buds of its green leaves yielding only the slightest hint of spring hidden deep within. The late afternoon sun casts a slender shadow across the sodded common area. One by one they come—soccer moms; big moms, little moms, moms who climb on rocks; fat moms, skinny moms, even moms with chicken pox—sorry, I couldn’t stop myself—as they will every day at this same time, seeking protection in its shade. My neighbors.  It’s only sixty-five today, yet they seek protection from the nonexistent heat, a habit born no doubt from bygone sweltering summer days. A ritual. An inability to change. In a few weeks the leaves will be in their full glory, and the moms will remain in the shadow of what once was, standing shoulder to shoulder facing outward, scanning the horizon for the bus. A herd. Just like wildebeest.

The children debus–I invented the word.  Mine hand me their backpacks, lunch boxes, and musical instruments.  I look like a Sherpa making my way home from K-2.

I shared the wildebeest analogy with the neighborhood moms—the bruises will fade gradually. I can state with some degree of certainty they were not impressed with being compared to wildebeest. So here we go, buckle up. By now you’re thinking, “There must be a pony in here somewhere.”

Some things never change; it’s not for lack of interest, but for lack of a changer.  For real change to occur someone needs to be the changer, otherwise it’s just a bunch of people standing shoulder to shoulder looking busy. Motion is not the equal of movement.

How are you addressing the change that must occur to improve patient experience?  Patient experience is not about CMS.  It’s not about purchasing data about patient experience, and it is not about coaching and clowns.  It is about moving from a 0.2 business model to 2.0.  You need someone who sees the vision of what is is—sorry, too Clintonian—must lead.  Be change.

One of the great traits of wildebeest is that they are great followers.

Will Showing Initiative Get you Voted Off The Island?

Were one to judge America by what American’s read from scanning the headlines of the magazines in the supermarket’s checkout lane, the only items of note are that Jennifer Aniston may or may not be pregnant, and that another one of the Kardashian’s was married—no word as to whether or not she is pregnant but I have my fingers crossed. The headlines provided no indication that we are at war or that the economy has been outpaced by my daughter’s lemonade stand.

Anyway. I have been reading Solzhenitsyn’s The Gulag Archipelago, which should be on every reading list for Genocide 101. In the book Solzhenitsyn describes numerous offenses which could get a Russian sentenced to Stalin’s gulags. Some estimates suggest more than sixteen million people were purged under Stalin’s regime—enough people whereby those in power had to continuously invent new offenses.

In one such description Solzhenitsyn recounts a meeting of Stalin’s supporters. By law, every public gathering was attended by several members of the NKVD, Stalin’s henchmen. At the conclusion of the meeting its chairman called for a verbal salute to Stalin which resulted in all of those attending applauding. The vigorous applause continued for eleven minutes because everyone was afraid to be the first to stop applauding.

To stop applauding was to show initiative, was to be an individual. Exhausted, the chairman finally stopped clapping; immediately, so did everyone else. The chairman, a loyal communist, was arrested. During his interrogation the interrogator told him “Don’t ever be the first to stop applauding. We do not like initiative.” Darwin’s natural selection and how to grind down people with stupidity.

Nonetheless, we return to Beaver Cleaverville.

Do you ever sit in a meeting thinking it would be easier to design a revolving sliding door than to agree with or understand whatever is going on in the meeting around you? You scan the room eying the seated rams and ewes each of who view themselves as lions. Once again, the Pickle Factory’s leader had confused motion with movement. You scribble yourself a note using your favorite crayon—the cerulean blue, ‘I have seen our future and it needs work.’

“Well, here we are,” says the moderator outfitted in her J C Penney imitation Vera Wang pantsuit. For years her mind has run just fast enough to enable her thoughts to always be in the same place.

“Yeah, here is where we are,” you mumble into your cupped hand. “We have been here before and we will be here again and again.” The person across from you seems to be humming “It’s a long way to Tipperary.”

These meetings make about as much sense to you as the game the Afghan Pashtun tribesmen play—buzkashi—sort of like polo except instead of using a ball they use a headless goat. Each day the executives drag the headless carcass of their business strategy to meeting after meeting hoping to score, and the more meetings you attend the more you feel like the goat.

“What are we supposed to accomplish today?” You ask.

“Your guess is as good as mine,” replies the moderator, her mind making its way back from its visit to the land of ultima Thule.

“No, your guess is better than mine,” you say. “It is your meeting. Lock the gate,” you mumble, “before the village loses its idiot.” Everything is running behind and the team wants to make up for lost time. Your job is to try to convince them that you cannot make up for lost time; the best you can hope for is not to lose any more.

You have always known that companies which do not tolerate dissent have a tendency to ignore dissenting information but they remember the dissenters—the first person to stop clapping. In a company lacking second sight and new ideas, the old ideas are often divided evenly among the employees. The death spiral of silence—people avoiding threats of being voted off the island have a tendency to refrain from making any statement that may show them to have an original thought. Showing initiative can result in your being sent to the company’s gulag.

Have you noticed that the more a firm’s competitive edge erodes, the busier the firm appears to be? Once you have fallen through the looking glass the only way out may be for you to walk back the cat, that is travel backwards to see how it is you and the others became trapped in this wilderness of mirrors. The problem with that strategy is that to undertake it requires you to show initiative.

Every firm’s gulag is filled with people like us. At least when you get there you will be able to commiserate with people of a similar ilk.

What if you were actually able to do the one thing that you were most afraid of trying in your firm?  If the idea is good enough it may be worth getting voted off the island.

Patient Satisfaction: How Many Days Ago Was Sunday?

How long have you been doing this?  That’s seems like a fair question to ask of anyone in a clinical situation.  It’s more easily answered when you are in someone’s office and are facing multiple framed and matted attestations of their skills.  Seen any good Patient Satisfaction or retention certificates on the walls of the people entrusted with the execution of the hospital’s patient experience endowment?  Me either. 

I have a cardiologist and he has all sorts of paper hanging from his wall.  Helps to convince me he knows his stuff.  Now, if I were to pretend to be a cardiologist—I’ve been thinking of going to night school—I’d expect people would expect to see my bona fides.

Shouldn’t the same logic apply to whoever is spending the hospital’s resources to retain patients? 

Please permit me to offer a real-life example. More than ten years ago I had a heart attack and was taken to a local hospital.  I lived, thanks for asking.  For the last ten years I have done all of my cardiac follow up at U Penn, a different hospital.  The hospital that treated me does not know that I lived; they never called, I never heard from them again.  Cost of a phone call—$30.  Cost of not retaining me as a patient—quite a bit.

(This same hospital has a large business development team and an equally large marketing department that frequently markets its cardiology offerings.  Talk about an opportunity to cut wasteful expenses.)

Imagine this discussion.

“What do you do?”

“I’m implementing something for the hospital that we have never done.”


“The feds say we’ve got to have it.”

“Oh.  What’s it do?”

“Nobody really knows.”

“How long have you been doing this?”

“How many days ago was Sunday?”

“What’s it cost?”

“Somewhere between this much,” he stretches out his arms, “And this much,” stretching them further.

“Do the doctors want this?”

“Some do.”

“How will you know when you’re done if you got it right?”

“Beats me.”

“Sounds like fun,” she said, trying to fetter a laugh.

Sounds like fun to me too.


Patient Satisfaction: When you are in a hole, stop digging

I awoke this morning to a text message sent from my eleven year old son’s iPhone last night.  The message read, “My two girdles are killing each other.”

I was flummoxed until I spoke with my wife.  It was two gerbils that were killing each other.  Two gerbils, five dollars.  Autocomplete, priceless.

Having left my reading glasses at the hotel this morning I inquired of one of a my-gen coworker where I could buy another pair.  Judging by her stare, I do not think the twenty-something was any more familiar with the term ‘reading glasses’ than some people are with my epistles about patient satisfaction.

“Do you have trouble reading Dude, or are you looking for those Google glasses that read for you?”  She did not use the term Dude, I threw that in for effect.

I told her I did not have trouble reading and that I am able to read two years above my age level—bada boom bada bing.

I was thinking about the time I was teaching rappelling in the Rockies during the summer between my two years of graduate school.  Each one week camp was for high school students of varying backgrounds and their counselors.  On more than one occasion, the person on the other end of my rope, the person being rappelled, would freeze up from fear and I would either have to talk them down safely or rappel down or help them.

Late one day, a thunderstorm broke quickly over the mountain, causing the counselor on the end of my rope to panic.  No amount of talking was going to get her to move either up or down, so it was up to me to rescue her.  I may have mentioned in a prior post that my total amount of rappelling experience was probably no more than a few more hours than hers.  Nonetheless, I went off belay, and within seconds, I was shoulder to shoulder with her.  We were both perpendicular to the face of the cliff and some fifty feet from the bottom.

The sky blackened, and the wind howled, raining bits of rock on us.  I remember that only after I locked her harness to mine did she begin to relax.  She needed to know that she didn’t have to go this alone, and she took comfort knowing someone was willing to help her.

That episode reminds me of a story I heard about a man who fell in a hole—if you know how this turns out, don’t tell the others.  The man in the hole continues to struggle but can’t find a way out.  A CFO walks by.  When the man pleads for help the CFO writes a check and drops it in the hole.  A while later an applications vendor walks by—I know this isn’t the real story, but it’s my blog and I’ll tell it any way I want.  Where were we?  The vendor.  The man pleads for help and the vendor pulls out the contract, reads it, circles some obscure item in the fine print, tosses it in the hole, and walks on.

I walk by and see the man in the hole.  “What are you doing there?”  I asked.

“I fell in the hole and don’t know how to get out.”

I felt sorry for the man—I’m naturally empathetic—so I hopped into the hole.  “Why did you do that?”  He asked.  “Now we’re both stuck.”

“I’ve been down here before,” I said, “And I know the way out.”

I know it is a little sappy and self-serving.  However, before you decide it’s more comfortable to stay in the hole and hope nobody notices, why not see if there’s someone who knows the way out?

John Steinbeck’s novel Of Mice and Men included the statement, ‘The best laid plans of mice and men often go astray.’  My take on it; the reason the best-laid plans of mice and men often go astray is not the because of the plan; it is the mice and men. 

The problem is mice and men have a history with the organization.  They are constrained by phrases like ‘We’ve never done it that way’ and ‘that cannot be done.’  I believe most things people think cannot be done can be done, but then I have been accused of trying to believe in as many as six impossible things before breakfast.

One of the impossible things I believe is that there are simple ways to dramatically improve patient satisfaction for all patients by creating a remarkable experience for every patient every time.  Every time a patient or prospective patient interacts with the hospital they do so in one of three ways; they call, they go to the web, or they do so in person.

Each person is either satisfied or unsatisfied from every call, web visit, and visit.  The health system needs to get these interactions right one hundred percent of the time.  What does it mean to ‘get it right’?

If I go to the web to schedule a follow up appointment and I am given a number to call rather than an appointment, the hospital failed me.  If I call the hospital to understand Medicare billing and am told to call back during normal hours, the hospital failed me.

Finally, suppose using my Bluetooth headset on Dragon I use my iPad, and with voice commands navigate to the link on the hospital’s website showing me how to retrieve a copy of my medical records.  When I get there, having used every possible form of technology, I am instructed to click a link to open a form to request my records.  I then must print the form, complete it, find an envelope and a stamp, and post my request via snail mail.  Over the next few weeks the hospital will reverse the process and eventually I will receive my records.  My satisfaction dropped?  Why?  Because the link implied I could click something and get my records; the fulfillment process was out of date and under-delivered.

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.

9% of Hospitals Have a Patient Satisfaction Plan

The phone rang last fall. It was the school nurse asking me if I would pick up my seven year-old son. When I inquired as to the reason she informed me he delivered an organ recital—a long-winded recitation of ones ailments—the classic symptoms of the crud; tummy-ache, non-responsive, crying. She’s the nurse, so without better information, who was I to question her diagnosis?

We got into the car and his tears started flowing. “Do you feel like you’re going to be sick?” I asked as I looked at the leather upholstery. He didn’t answer me other than to whimper. He didn’t seem sick at breakfast. I remembered that he was crying last night, but his tears had nothing to do with his stomach. While he was crying he was hugging his favorite dog, our five year-old Bichon.

We had just learned that the Bichon was very ill and will never be a six year-old Bichon. The person having the most difficulty with the news is my youngest. I asked him if that was why he was crying in class and he confirmed it was. Dads know everything, at least some times.

So, here’s the deal. The school nurse had done all the right things to diagnose my son’s problem, but she stopped short of determining what was wrong. Let’s try a more relevant situation from the perspective of patients and what they think of their interaction with the hospital. 

A survey of 1,004 physicians and nurses in four countries found that 90.4% said improving satisfaction of patients during hospitalization was achievable. But only 9.2% said their department had a structured plan to boost patient satisfaction, March BMJ Quality and Safety.

What does the hospital know about what their patients think about them?  Has anyone ever asked of a patient, “What do you expect from us throughout your experience?”

At minimum patients expect that when they call the hospital they will receive a correct answer to any question they ask one hundred percent of the time.  At minimum patients expect that when they go to the hospital’s website they will find what they need or accomplish a given task one hundred percent of the time.

Does that happen?

Didn’t think so.  Planning to meet expectations without knowing what they are is a lot like playing on the tail on the donkey; blindfolded, spun around, and set off to hit the target.  Failing to plan for patient satisfaction is planning to fail at satisfying patients.

Hospitals are spending a lot of money and losing a lot of patients by trying to diagnose their patient satisfaction problems.  The problem is they quit diagnosing the problem before they find the answer.  To make matters worse, very few hospitals are even looking in the right place.