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.