Hospitals: Customer Care in a bad way!

Hospitals strive to provide compassionate care and to treat all individuals with dignity and respect. BUT do they?

We’ve all heard about the horror stories in doctor’s waiting rooms or other medical facilities – stories of patients being forgotten for hours, lost files and paperwork, long waits, and a lack of information through the entire medical process.

Hospital care or service is not about beds, bed pans, doctors, nurses, laboratory, cribs, hospital gowns, etc… It’s about helping people feel better. And helping people feel better emotionally.

Some hospitals say they are committed to continually improving customer satisfaction. They regularly survey families of patients for input about their performance, and they train all employees in customer service. Families (who are their customers) expect and deserve outstanding clinical care, and they realize they must deliver care with respect, compassion and sensitivity.

Often their statements of service standards identify the qualities and behaviours they expect employees to demonstrate in all interactions with patients, families and each other.

In his book entitled “If Disney Ran Your Hospital” Fred Lee identifies what they would do: -
1. Perceptions Vs. Reality
2. Courtesy Vs. Efficiency
3. Patient Loyalty Vs. Patient Satisfaction
4. Experience Vs. Service Vs. Product
5. Intrinsic Motivation Vs. Extrinsic Motivation
6. Habit Vs Imagination Vs. Willpower Vs Compliance
7. Dissatisfaction Vs. Complacency
8. Doing Vs. Knowing

Perceptions are more important than reality

If Disney Ran Your Hospital, patient perceptions of care would be more important than the actual care they received.

When Andre Agassi was still in the peak of his career, Canon advertised their new “rebel” camera with Andre, and the tagline: “Image is everything.”

Lee explores a slight variation of that: perceptions are more important than reality.

Pretend you are a patient in a hospital. It’s late at night and you are half-asleep in your room. The nurse comes in, checks up on you and then quickly closes the door as she leaves. How do you feel? You might think she’s in a rush to get to another patient (wow, this hospital is always so packed). You might think it inconsiderate (hey, I wanted that open!). Or maybe the nurse went out to talk behind your back.

The truth was the nurse knew that the next shift was coming in and it would be getting loud outside. The truth is that she closed the door to minimize the noise from the shift changing. She closed the door because she’s a considerate nurse. But you didn’t know that. You’re still thinking about what you did to deserve this.

Good intentions and good care don’t always lead to the perception of good care.

To impact patient perceptions (and thus, satisfaction), good intentions have to be verbalized. This isn’t showing off or brown-nosing. This is simply matching up your actions and words with your intentions in order to assure the patient and to avoid misunderstanding.

The nurse could have left, asking “Do you want me to close the door? it gets kinda noisy out there during shift change. It won’t be too much longer.” That 10 seconds of verbalizing done over 1,000s and 1,000s of patient interactions creates a perception, “hey, these people are looking out for me.”

All of us are all too familiar with this idea from everyday life. We incorrectly read into things, others incorrectly read into our actions.

Hospitals have to see every interaction with patients from their perspective.

Courtesy is more important than efficiency

If Disney Ran Your Hospital, courtesy would be more important than efficiency.

This is true at Disney. They don’t use “pillars of excellence” like healthcare where all five priorities are balanced (and the relative importance of each is unclear). Disney makes it more blatant by using a ladder instead of a pillar – pillars don’t help you prioritize, ladders do.

On Disney’s ladder, safety is priority #1, followed by courtesy, then show (related to perceptions), and THEN efficiency. Long ago, Disney realized this (and Lee provides a great flowchart here):

Unit efficiency focus –> Internal focus –> Turf Protection –> Compete for Resources –> Overall inefficiency

Courtesy focus –> External focus –> Responsiveness –> Share Resources –> Overall efficiency

In other words, focusing on efficiency actually makes you inefficient (and probably not too responsive) where as focusing on courtesy gets you BOTH efficiency and responsiveness.

Hear what Lee is NOT saying: He’s not saying that hospitals should throw efficiency out the window. Nor is he saying that hospitals should stop measuring cycle times and think about process improvement. But too many times, process improvement initiatives are “department-centric” not “customer-centric.” These so-called improvements make the department more efficient, but only because they’ve shifted work to other departments.

Sometimes optimizing one cog in the machine makes the whole machine slower.

Lee mentions several stories of hospitals who took the courtesy plunge and succeeded. One hospital dramatically changed their food service. They initially had the “efficient” model of meal delivery for patients at set times, 3 times a day. If patients happened to miss the meal, too bad – kitchen closed. Wanting to provide better service, the food service department evolved to the point where it delivers food all day long, and not just to patients, but also to staff, to physician offices, and anyone who finds themselves in the hospital. The tripling in volume + decrease in wasted food costs more than paid for the extra labor required.

Patient Loyalty is more important than patient satisfaction

If Disney Ran Your Hospital, they would focus on patient loyalty instead of patient satisfaction. That’s right. Disney is arguably one of the greatest organizations in the world and they don’t measure customer satisfaction. But they are relentlessly looking at customer loyalty. Why? Loyalty, not satisfaction, is what drives repeat business. In patient satisfaction vernacular, loyal patients give a rating of 5 out of 5, while “satisfied” patients give a rate of 3 or more. In an essay written in the Harvard Business Review on “The Loyalty Effect” by Reichheld, customers who give a 4 rating are 6 times more likely to defect compared to 5-raters. Patient satisfaction surveys are an odd beast. If nothing goes wrong, if nothing memorable happens, the patient would probably check off “3″ or “4.” Additionally, if a hospital achieves “98% patient satisfaction,” why would any staff feel the need to improve? They would rest on their laurels while patients simply had a ho-hum experience. Disney aims higher. Their measure is the % of customers that rate their experience “very satisfied” (rate 5 out of 5).

For patients to be “very satisfied,” something memorable, something unexpected, something worthy of a dinnerparty story, has to happen.

Now, of course! It’s Disney! Not a hospital where people come in sick, hurt, afraid, and stressed! How do hospitals create “storytelling moments”? Lee did some research on unsolicited positive feedback from patients. The main theme? Compassion. Patients remember compassion. Human beings remember compassion, especially when they are in need. Compassion can become the chief point of differentiation in hospitals. How? It has to be recruited, valued, and measured.

In the book, ‘The Experience Economy’, the authors provide an insightful commentary of where the American economy is headed. Back in the 1800s, the economy was driven by commodities – cotton, water, oil, steel, etc. Then, after the industrial revolution in the early 1900s, the economy was driven by manufacturing – i.e. clothing, cars, refrigerators, TVs. In recent years value has been created through services (relaxing spa, trusted investment advice, friendly dry cleaning). The 4th revolution has begun relatively unnoticed – the customer experience.

Take coffee as an example. The theory is that every step up gives you 5-10x more value. Coffee grinds run maybe a few cents. Package it into a product? maybe 20 cents. Brew a cup and sell it – about a dollar. Cozy up in a warm sofa at a Starbucks with a grande dark roast coffee, $4.

Lee quotes the authors: “Commodities are fungible, goods tangible, services intangible, and experiences are memorable.” The main principle is that experiences are personal and individualized.

One has to stop thinking of hospitals as providing a service or a product. We have to start thinking about our hospitals as providing an experience. What kind of an experience? As Lee puts it, an experience that “engages patients on an emotional, physical, intellectual, and yes, spiritual level.” And the quality, consistency, and substance of that experience may very well become the primary differentiator of the hospital. What can we do today that will make this patient visit absolutely memorable?

Scripting has to be more than words on a page, but setting up an entire experience, scene by scene. Hiring should be done based on one’s talent to engage the patient. Think of roles, not jobs. In some sense, every patient room is a stage.

How do you motivate and reward compassion?

If Disney Ran Your Hospital, they would motivate employees through the mission of the hospital, not the amount on their paycheck.

Disney doesn’t utilize pay-for-performance. Nor do they utilize a “forced” curve where a certain percentage of workers get higher raises than others. In environments where teamwork and lateral relationships are key to success, such incentive structures don’t work – and even more, they are destructive and demotivating.

Lee also gives some good examples of this.

THE OVERZEALOUS MANAGER: One manager wanted to encourage her employees to write “letters of appreciation” to other employees in the group. Very few people actually did, so she decided to provide some incentive – for every letter, the writer would get a Pepsi. You can imagine what happens next – Not surprisingly, she yanked the whole thing a week later – $50 poorer and no one taking any letter seriously.

OLD MAN STOPS INSULTS FROM KIDS BY PAYING THEM TO INSULT HIM: You’ll find it on page 179 in Fred Lee’s book. Kids insult old man. Old man ignores them. Day after day, kids keep insulting old man. Old man decides to pay kids a quarter for each insult. The next day, tons of kids come and insult. The next day, old man says, “too many kids. Now I can only pay you a penny for each insult.” Kids go away insulted and stop insulting old man for good.

An illustration of how extrinsic motivations can derail intrinsic motivations!

This is a fine line. Hospitals need to be careful how we reward “compassion.” They need to avoid the situation where people do compassionate things in hopes of the reward while their real sense of compassion is no where to be found. On the other side of the coin, we also want to recognize those who display compassion sincerely and spontaneously. Just as the display of compassion is spontaneous and not required/expected, so should the recognition be.

Motivating others through imagination, not willpower or compliance

If Disney Ran Your Hospital, employees would be motivated by their imagination instead of their obligation to comply.

Fred Lee describes the human heart. In particular, the primary motivation of the human heart? He describes 4 levels:

1. Compliance: I do it because I have to do it. (or I’ll get in trouble)
2. Willpower: I do it because I should do it (I don’t like it but I know it’s what I should do)
3. Imagination: I do it because I want to do it!
4. Habit: I do it because it comes naturally for me to do it.

Lee links imagination with compassion this way: you have to really try to imagine what the patient is going through, what the patient’s family is like, what the patient is thinking. Through that imagination process, you are growing your capacity for compassion.

That’s what good actors do – they are able to relate to their characters so much so that they are truly feeling the raw emotions of their character. The best actresses who cry on screen are crying real tears – many conjure up the saddest moments of their lives and allow themselves to feel those emotions on screen. Whatever the character feels – loss, love, fear, determination – the actor draws from the emotions of their daily lives.

Ultimately, all good actors have sincere compassion for their characters. They use their imagination to feel what the character is feeling. Good acting doesn’t look like acting because it’s real people showing real emotions!

In the same way, Lee encourages hospital staff to imagine the emotions and thoughts of their patients. Drawing on their own life and truly seeing the patient’s needs – this is the essence of empathy and compassion.

Leaders must become artists – they must master the art of motivation. Capture people’s imaginations, and hospitals will have patients who will tell memorable stories about staff over dinner.

Employee dissatisfaction is in, employee complacency is out

If Disney Ran Your Hospital, employees would have a healthy dissatisfaction with their current performance.

They would always be thinking/ scheming/ dreaming/ striving for the next level.

Fred Lee shares a recipe from Martin Stankard, a national Malcolm Baldridge Award examiner:

Dissatisfaction with “as is” + Dream of “could be” + knowledge of “how to” > Organizational Interia.

Part of creating a “culture of dissatisfaction” is using statistics wisely. If patient satisfaction scores are already at 95%, what motivation do people have to change? Disney measures the % of all respondents who are “very satisfied,” the 5 out of 5 scores. That creates the kind of environment where staff get creative.

Part of “dream of could be” is to help your staff envision what greatness would taste like, feel like, smell like, look like.

All 3 ingredients are needed. Vision alone becomes lofty ideas that are quickly forgotten and subjugated to the daily demands of the job. Dissatisfaction alone creates frustration, angst, and a destructive culture. Knowledge alone has no way of energizing and persisting in change. Leaders have to provide all three.

Doing is more important than knowing

if Disney Ran Your Hospital, actions would be more powerful than ideas.

Fred Lee highlights some traps that many organizations fall into in trying to close the gap between knowing and doing. Too many leadership teams delegate the management of culture and change to committees, consultants, individuals, and trainers. These initiatives are doomed for failure. The leaders have to be directly accountable. Culture and change are much too important to be delegated.

Also, too many organizations suffer from analysis paralysis. The leaders of the organization must be willing to put in the hard work in hardwiring excellence. It’s good to ask “how?” but at some point, they have to roll up their sleeves and dive in.

~ by Steven Viviers on May 16, 2008.