He had a series of complications toward the end.  He had a colostomy as well as two nephrostomy tubes.  Most of the work for the colostomy could be done at home but the nephrostomy tubes had to be surgically re-inserted periodically.  On his last visit for the procedure, two weeks before he died, my dad looked at the nurse as she was preparing him and said, “You won’t keep me here, will you?”  Even though it took three of us to get him out of his bed at home and into the car via a wheelchair, my dad did not want to be in the hospital and preferred the physical strain it cost him to return home.

Knowing what I know now about dying — and dying from cancer, I can still say that dying at home, without the fuss of hospital policies/standards/protocols etc. provided a more comfortable and private place for my dad and my family.  For us, the ultimate patient experience was a quiet and private passing.  Hospice nurses and aides took great care to make sure my father was comfortable, clean, with limited pain and in good care.  They took extra steps to help my mother and me know what to expect and what we could do to help my father.  They stepped out when our questioning was done but stood ready to help, steward and comfort us.

According to the Journal of Clinical Oncology as reported by Reuters (September 13, 2010), at-home hospice care saves money, reduces emotional distress for caregivers and leads to a more peaceful end-of-life passing. While most cancer patients indicate they would prefer to die at home, more than 36% will die in an acute care setting.  Over 25% of Medicare expenditures are spent in the final month of life, most often in intensive care even though there is limited evidence of benefit for the patient.

Physicians and healthcare organizations can help patients and their families in this final quest for a positive patient experience by providing more conversation around the planning for the end of life.

Research conducted by the Agency for Healthcare Research and Quality (AHRQ) indicates the following:

• Less than 50 percent of the severely or terminally ill patients surveyed had an advance directive in their medical record.
• Only 12 percent of patients with an advance directive had received input from their physician in its development
• At least 2/3 of physicians surveyed whose patients had an advance directive were not aware that it existed.
• Care at the end of life sometimes appears to be inconsistent with patient preferences of forgoing life-sustaining treatment.

As health care professionals and as family members, let’s not leave out the important conversation about end-of-life issues.  Talk it over, ask questions, review with each other and make sure that when the time comes, you AND your loved ones understand what is important.  Knowing that my dad died in the manner he hoped makes his absence more tolerable.

Since his health started to take a nose dive in June 2010 and I moved him and my mother to live in my community, I have been forced to see the healthcare industry as a “family member” and have considered our culture’s struggle with morbidity and mortality.

My dad is still with us but the prostate cancer is voraciously taking over.  And even though my dad is 82, he is fighting death.

I don’t know what direction my future posts will take but I just want to offer up some bullet point thoughts for now:

• I am thankful to Northern Berkshire VNA + Hospice for their continuing care and guidance for my father and our family.  We would be lost without them.  And I am so thankful that my father’s primary care physician recognized the value of hospice sooner rather than later.
• We have encountered several physicians and nurses who extend their knowledge and care by their grace and kindness.  Berkshire Medical Center has several providers in their medical community that work hard to combine true compassion with competency.  It is these individuals who are the heroes in healthcare delivery.
• Insurance and payment continue to drive the “system” in interesting ways.
• Medicare, supplemental insurance, out of network, transferring care into a new state – how complicated does it need to be for our seniors?
• Our “system” of delivering care is fractured enough that the actual delivery of care becomes problematic and certainly expensive.  Why is the primary care physician essentially out of the information loop during hospitalizations?  Why does one man dying from prostate cancer need a primary care physician, an oncologist, an urologist, a surgeon and an interventional radiologist?
• Testing, testing and testing?????  And an end of life, how much do we really need to know?
• Patient-centered care is about the individuals delivering the care, the organizational system structuring the care and the overall corporate culture.  As an industry, we still struggle with the delivery of patient-centered care.  Try being a patient for one day in your organization and see how well you do.

Okay, this isn’t meant to be a rant, especially because my father has enjoyed exceptional care in North Carolina and now in Massachusetts.    We do need to think long and hard about healthcare delivery. We who dwell in this industry are the individuals who can work to change things. We do need to consider the demographic pressure as the baby boomers age – both in terms of costs and appropriate care.  We do need to consider the lack of primary care that is already impacting rural regions. And we do need to understand that all individuals can impact their own healthcare – simply by the food we eat (plant based, anyone?) and the exercise we have. As the new batch of Republicans vow to dismantle last year’s healthcare reform, should we take the time to communicate to our local politicians about what we know?

Way too many of us cut the corner of simply making assumptions and neglect to ask our customers what is really on their minds about our healthcare service. We are missing out on good opportunities to continually improve and grow our services.  I often hear the lament of how frustrated primary care physicians are about the lack of feedback they receive from consulting physicians or patients who tell their friends their frustration about the service they didn’t receive at their doctor’s office but don’t tell the people who can fix the problems.

Get in the habit of seeking feedback.  Whether positive and negative, feedback, can help tune work processes and services to better suit your current and future patients/customers. Obtaining feedback can move your healthcare organization from ordinary to extraordinary.

Varying Methods of Collection

There are many different ways to obtain the feedback.  There are several different on-line services that you can use such as SurveyMonkey or PollDaddy. Using such a site will help you create a survey of any size with the option of conducting analysis once the data is collected.  Or consider creating a quick survey on your website asking key questions or instill a face to face feedback moment at the end of a visit – give them a form or ask them to meet with one of your staff members to go over some service oriented questions.

Questions to Ask

Once you are in the habit of seeking feedback from your customers, you will seek out input on a variety of things.  Typically you will want to know about how your service is valued, what are road-blocks in the delivery of that service?  What can be done better and what is already done well.  Your questions will reflect what your interests are but here are some example questions:

• How old are you? (knowing this information can help you tailor the delivery of your service based on generational differences.)
• Why did you choose us as your service provider?
• How long did you have to wait before you were provided with an appointment?
• How would you rate your overall satisfaction with our service?
• How would you rate the overall customer service you received?
• Did you consider any alternatives to our service? If so, how did you make your decision?
• Are you familiar with our website? (This can lead to several other website questions)
• What do you wish was different about our practice/service?
• Would you recommend us to your friends and family?  Why/why not?

The Last Thing to Consider

What do you do with the data once you have collected it?  Be sure to systematically analyze the information you are receiving.  Set up studies so you can chart improvement and catch problems early on. Thoroughly review data to determine if you should change services, personnel, customer service efforts. Your patients are a great source of insight for your continued and future success as a healthcare provider.

The American Society for Hospital and Human Resources Administrators recently released a study of the workforce trends for the year 2015.  Entitled, “Strategy Trumps Shortage”, they came to the following conclusions:

• Work processes will need to be redesigned
• Retention of existing staff is critical, even those able to retire
• Companies must do the right things to attract the new generation of worker

While on the surface, these conclusions don’t seem to be much different from what we have heard in the past, when you put them into the context of the current generational shift going on in the work force, they are actually quite relevant.

Let’s start with work processes…By 2015, the majority of our workforce will be made up of Generation Y and Millennials.  These generations thrive on independence, rapid feedback and a desire for balance between their work and personal lives.  They are much more likely to judge their organizational experience on individual relationships…not on the overall organization.  Therefore, they will chose to work for places where they can exercise their creativity within a flexible work environment.  Are you designed to meet their needs as an employer, or does a top down, hierarchical environment best describe you?

Thinking about retention of staff, one of the greatest expenses a company incurs is in losing a staff member.  The hard costs of a turnover include the money spent to fill the gap until a person is hired (overtime, temporary staff), training time for the new person, loss of productivity during the training period and others.  While some turnover is good, it’s key to understand who you are losing.  If it’s your good people, something in your environment needs to change.  Your good people can always find a job, and they are the ones providing the great experiences for your customers.  You cannot afford to lose them.  Find out what motivates your top performers to stay.

What about attracting the new generation of worker?  As noted above, the newest generations look for a workplace that will allow them the freedom to not only do their jobs, but to also design how they would like to do those jobs.  While there are certain requirements and rigor to each job, it’s important to look at where you can be flexible.  While tradition is important, doing things the same old way just won’t endure.

To meet these challenges, the study noted that there are certain leadership approaches that will be necessary to create environments so that employees will be energized and focused on providing your customers with great experience.  Some of those traits include:  an appetite for change, the desire to engage the workforce, the thirst for innovation and an approach that welcomes new generations to the workplace.  Do your leaders possess these traits?

To best serve your customers, you must best serve your employees first.  Make it a focus for 2010 and you will see great results!

OUR GUEST BLOGGER:  Catherine Baumgardner has extensive experience in leading operations of clinical services for a regional health system, and in consulting with clients to develop and implement strategies that will deliver desired results. Her outstanding skills in customer service culture development and implementation have made her a favorite choice with her clients.  If you are looking for someone with a strategic awareness to customer experience and operational excellence, Catherine is a good person to contact.  She recently started her own consulting firm, Catherine Baumgardner and Associates and we are pleased to have Catherine as our first guest blogger!

Prior posts have enumerated the value of a customer relationship management (CRM) systems and how important your front line personnel are to enhancing your relationships.  Go a little further in your thinking and look at your entire work flow process but do it from the eyes of your consumer.  “Mystery shop” your own service and see how it feels to be the referring physician or the patient.  What are the gaps in service?  Do all of your employees recognize that their primary goal is to make the consumer feel good? Are there clogs in the process?  Does the patient or the physician have an easy vehicle in which to make suggestions?  Is your service fixed or do you recognize the need for constant refinements?

Intense competition makes it harder for healthcare organizations to keep their consumers satisfied and loyal. Simply put, better service results in happier physicians/patients which results in repeat business and increased revenues. Use your workflow to enhance the consumer’s experience and to make them happy.  Don’t get caught in the trap of focusing on the business goals that are pressing but make sure you have the basics being met for your patients and physicians.  Is your workflow process focused on achieving the organization’s business objectives and less concerned with improving customer relationships?

Look at your process by first identifying customer needs. Consider what work should be done, who should do it and if there is technology that can support the work and make the process more efficient.  Keep in mind that the healthcare consumer is more informed and wants to be more involved in the process.  The patient who listens and follows the doctor’s suggestions without questioning is less and less common.

You may be tempted to tweak your process here and there but consider a strategic look at the entire process and how it feels from your consumer’s reference point.  If you examine the who, what and where of your operations, you might be pleased and surprised by the changes you can make.

Cleveland Clinic

“Patients are the purpose of our work, and Cleveland Clinic has embarked on an ambitious plan to examine and improve every facet of the patient experience. This effort encompasses every point of contact between patient and provider, from parking to prescription pick up.”

Johns Hopkins Health System

“Our quest for excellence isn’t limited to the treatments we provide. Several initiatives are under way at Hopkins to help physicians, nurses and staff to deliver the best possible service to customers.”

Gettysburg Hospital

“Gettysburg Hospital is ramping up its commitment to patient satisfaction with the aid of a qualified specialist. Tracy Lee joined the hospital last September as director of patient experience. Lee tracks patient satisfaction survey results and develops strategies for improvement.

Lee explained that many health systems have placed renewed emphasis on patient satisfaction in recent years.  A federally mandated consumer survey known as HCAHPS—the results of which are available to the public—has driven that trend.

“We all know what it’s like to either be a patient or have a loved one in crisis, and I enjoy helping make that experience a better one,” she said.”

These three organizations could not be more different from one another. And yet is placing special emphasis on the patient experience.  Each of them are defining that experience as beyond taking care of a patient clinically:

• “…every point of contact between patient and provider.”
• “Excellence isn’t limited to treatments we provide.”

When a patient visits the hospital or a doctor’s office, that individual experiences a series of events that often overshadow the actual contact with the medical provider. On a recent medical visit , I spent 15 minutes with the physician and 45 minutes “in process” once I entered the office – time at reception, time in the waiting room, time with the med technologist, time waiting in the exam room and time checking out after the visit.  It is easy to see how a good interaction with the physician can be overtaken by less than stellar service interactions.

You have heard me say that service is the marketing and that phrase is so true when it comes to the patient experience.  If you patient leaves happy, they will consider the experience positive and likely share that with their friends and family.  They will probably want to be your patient for a long time and will refer others to you. Their positive experience will create a long-lasting relationship value for them.  If your patient leaves grumpy, none of these good things happen.  In fact, a patient is more likely to share bad service news than good news and in telling their friends and family, you are on your way to a poor reputation.

So, think about, how high is your patient experience bar?

In the majority of cases, patients choose your service or your practice because someone they know suggested it – the old “word-of-mouth” rule.  Whether that person is their primary care physician or their Aunt Millie, that referral gets the patient in the door.  That’s where the 80/20 rule comes into play.  That referral is only 20% of starting the relationship.  What happens next to that patient creates the bulk of their sentiment toward your service.  It sets the platform on whether they will come back and what they will say to their family and friends.

Fortunately or not fortunately, in health care, we have a pretty low bar when it comes to the patient experience.  While you might want to make a site visit to your competition and see what they are actually up to when it comes to the 80% factors, you can run down the following list and ask yourself the likelihood of any medical organization doing the following things well:

• Will your patient have an easy time parking?
• Will it be easy for your patient to make their way to your office?
• Will your patient be greeted warmly and with rapt attention?
• Will visit expectations be established and communicated to the patient so there will be few surprises for the patient?
• Will anyone coming in contact with the patient be polite and attentive and limit conversation to others if not relevant to the patient?
• Will the patient’s privacy be respected?
• Will the patient’s comfort be of the utmost concern for all who come in contact with the patient?
• Will the process and procedure be explained in advance of action and with the patient’s comprehension?
• Will the service being provided be for the patient’s convenience?
• Will the providers who come in contact with your patient act as if the patient were a close family friend?
• Will instructions and expectations for after the visit be explained, perhaps even written,for the patient?
• Will follow-up calls be made to check-in on the patient after they have gone home?
• Will family members or those accompanying the patient be kept apprised of the patient’s progress and made to feel comfortable?

You can make your own check-lists and be more specific, but the point is make a difference in the life of your patient by working on those 80% factors that will help the patient prefer your service to your competition’s service. This good and hard work will help the patient choose your organization for other services and establish the foundation for a long-term relationship.

Snow has fallen, holiday lights twinkle and the bustle of the holidays are upon us.  I am thankful for today – a Monday – so I can catch up with myself.  The weekend was too busy!  Too much rushing; too much doing – a lot like each day. Perhaps this holiday season, it won’t just be about the “doing” but a lot more about the “being” and maybe understanding more about “others” and how our actions make a difference in the lives of those others.

So, as a departure from the routine and thanks to Paul Levy’s blog, Running a Hospital, I share this touching acceptance speech by Amy Ship, M.D., a primary care physician, as she is awarded this year’s Compassionate Caregiver Award by the Kenneth B. Schwartz Center. It is an elegant speech full of grace and humanity.  No matter where we are on the healthcare delivery continuum, it is good to consider, “the power of the smallest gesture” and to recognize that there is “no billing code for compassion.”  Thank you, Dr. Ship, for the caring that you exemplify and the teaching that you do.

Below is the Raymond Carver poem that she references and quotes in her speech:

What the Doctor Said

He said it doesn’t look good
he said it looks bad in fact real bad
he said I counted thirty-two of them on one lung before
I quit counting them
I said I’m glad I wouldn’t want to know
about any more being there than that
he said are you a religious man do you kneel down
in forest groves and let yourself ask for help
when you come to a waterfall
mist blowing against your face and arms
do you stop and ask for understanding at those moments
I said not yet but I intend to start today
he said I’m real sorry he said
I wish I had some other kind of news to give you
I said Amen and he said something else
I didn’t catch and not knowing what else to do
and not wanting him to have to repeat it
and me to have to fully digest it
I just looked at him
for a minute and he looked back it was then
I jumped up and shook hands with this man who’d just given me
something no one else on earth had ever given me

As a health care worker, you are probably shaking your head and saying to yourself that this patient doesn’t know what is important and wondering why my neighbor would decide on a service provider based on something so trivial?!  The thing is you have a broader concept and more information than my neighbor.  You might well chose your physicians based on their medical reputation but most people can’t or don’t base their decisions on medical aptitude.  They don’t have the knowledge to easily make that assessment so their selection criteria ends up being more superficial and typically service oriented.

As the medical provider, you can do one of two things:  1) be smug and feel sorry for my neighbor and the thousands of other people like her and do nothing to help them get past this first impression snafu or 2) you can recognize that there are a few hurdles that need to be met so that my neighbor and others are not stopped short of the actual medical service.

I hope you choose option two.

The first few minutes a prospective patient has in your office sets the stage for the future with that individual. You want to help that individual get past the greeting and feel good about what is to come next.  Think about the routine that happens in your office when a new patient comes in for the first time.  Are they “routinely” greeted and given a clipboard with your patient form and asked to sit down and complete the paperwork?  This is the standard in most offices.

What would happen if your office personnel changed their routine and treated that newcomer as a guest – someone special – who deserves attention.  Since most people come into the office for a specified appointment, it should not be difficult to greet them by name  (i.e. “Good afternoon, Mrs. Smith, we have been expecting you.”)  And if someone you don’t know shows up, the greeting should be just as warm but helpful and inquisitive (i.e. “Welcome to North Shore Medical, is there something I can help you with?”)

Go past the greeting moment and put your guest at ease.  Here are a few ideas to get you started:

• Ask to take their coat.
• Ask if they had any problem with the directions.
• Provide a brief tour of the office if they are new (this is our reception area, here is our lab for blood draws, patient exam rooms are all equipped with x, y and z and the doctor will confer with your in his office as you will see shortly, etc.
• Introduce the patient to other personnel, if convenient.
• Take a marketing moment and stop by the doctor’s diploma and mention that Dr. Smith is board-certified in X and is one of the few physicians who does Y.  We are so very proud of him. (Whatever makes you special is a good thing to share and also by having your staff member relay this information, it reflects on the team-like atmosphere of your practice and underscores the important professional information.  This act reinforces the good decision your new patient has made in selecting your practice for their health care needs.)
• Offer the patient refreshments.
• Give them an expectation for what comes next (i.e. “We will be checking your blood pressure and other vital signs shortly, but first why don’t you sit here for a few moments and look at some of our patient education materials while we prepare for you.”)
• You don’t ask them to complete the paperwork, because you have sent it out in advance so that the team has time to be familiar with the new patient prior to walking into the exam room.

All of this takes only a few minutes and not only puts your patient at ease but might even “wow” them with the difference.  Instead of leaving your new patient alone with paperwork, you have provided an appropriately warm, engaged, professional first impression.  And if my neighbor happens to be shopping by to compare, imagine the story she will tell me and ten of her other friends?

If you are extending your market, are you ready for it? Many hospitals tell me they are interested in extending their reach and developing a referral network within a distant market. Many of these hospitals have outreach personnel “selling” their services in those markets. This kind of outreach says “we are ready and you will like us!” On the other side of the equation, the physician and prospective patient give substantial forethought when going outside of their market and traveling for care. When this happens, your hospital has to be ready in ways you may not have considered.

For example, the coveted out of market patient has just experienced a surgical procedure and is ready to go home after a long day. All of the medical components to the visit worked well. There was a scheduling snafu so the actual procedure was delayed for a couple of hours so, it is 6pm when this patient is released. The drive home for this patient is in excess of an hour. What is likely to be extended or different for this type of patient?

Will the drive home require special handling – could the patient get dizzy or need to sleep? Should the patient be advised to spend the night in town? Will your hospital pharmacy be able to deliver normal expectations for this out of primary market patient? Can an educational element be added to make the sometimes two to three hour round trip be of more value?

What will the family member do if instructed by the discharge nurse that they should have a prescription filled before getting home. There was no pre-thought to the distance this patient would travel and no consideration to the fact the patient might need to access meds long before arriving home. What if the hospital pharmacy is closed? Ask yourself, is this the medical provider’s responsibility to think this through or the patient’s? If you want to please and impress that out of market patient and want others from that market to come, small details need to be considered that may see minimal but for the patient, they can be monumental.

Follow-Up

While all organizations provide discharge instructions, are these easy to understand, well organized and patient-friendly? Not to mention legible? Again, this is part of the lasting impression your hospital provides, make it count. It is also of considerable value – on the service side as well as effective medical care to have a provider or nurse conduct a follow-up call with the patient to discuss comfort and questions. This conversation can go a long way in helping a nervous patient have appropriate re-assurance and even un-do a negative service experience. This is also a great opportunity to collect input – just how did the visit go? Any issues? Logging issues from this first check-in conversation can serve as a service benchmark.

The Patient Experience – See It Through Their Eyes

Check, check your systems – are they as convenient as you believe? Does the parking valet or the receptionist believe they are “delivering” on your promise? If you are going to work hard to get the patient in the door, make sure you are delivering on the promise. Don’t have your hard work un-done with simple service elements. The patient is experiencing medical care and the associated service. For that patient, they are weighing the value and inconvenience of traveling out of their known market with the entire experience they have at your institution. You want to meet their effort head-on and leave them satisfied and maybe even a little surprised!