The Customer is NEVER Right - A Nurse Practitioner's Perspective
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And now...the rest of the story

As Paul Harvey would say, “And now…the rest of the story.” As mentioned in the previous LinkedIn article, although Press Ganey owned most of the customer satisfaction rating market in healthcare, and continues to do so today, there were a number of other companies doing the same in the 1990s, and still today. However, because of the inconsistent data from the different companies, the public complained to lawmakers that deciphering such data from different sources was challenging. Likewise, healthcare organizations also complained to lawmakers, except their complaints were that the rating was unfair for a number of reasons. Both parties also complained that the rating systems were failing in their intents of improving healthcare's quality and cost. Because of those complaints by the year 2000 the chatter began of standardizing how healthcare would be rated.

That cry from the public and healthcare organization and the following characteristic of healthcare—submissive, altruistic and accommodating culture, a lack of leadership and a junior-high school mentality, all would lead to the perfect storm. And a storm it has been. A storm that challenged the status quo, as the ceiling to moving the satisfaction needle had been reached. A ceiling that could no longer be moved by management, spending sprees—like that of luxurious lobbies and valet services to name but two of so many, and the hounding of outsiders—like Fred Lee and others, who declared the train for customer satisfaction had left the station and the only options were to either get on or be left behind as customer satisfaction scores was where healthcare was headed. Yet, despite their efforts, none of them could move the satisfaction needle any longer despite ALL the time, effort and billions of dollars invested.

On top of that, with the chatter of replacing outsiders with a federally mandated rating system outsiders panicked to find another IDIOT-OLOGY [sic] to save their cash cow of rating healthcare. Who can blame them?

Being the innovators they are outsiders scrambled to simply repackage and rename their failed IDIOT-OLOGIES [sic] of the 90s. They did so by changing their marketing from customer satisfaction to the new and improved customer EXPERIENCE, just like they have it at Disney. And this is where we find healthcare today where patients are now being called guest. That being the reason, believe it or not, as to why the Veterans Affairs (VA) Secretary’s comparison of Disney and the VA, and any other healthcare organization for that matter, are accurate.

To that I will add, not only is waiting in line not measured but the greater underlining message which no one talks about is that healthcare has been dragged, for decades now, down a slippery slope from which healthcare may not recover.

Yes, Disney and healthcare are apples and oranges. But ALL food* and more important food for thought.

All of that repeated to point this out, this notion that the current path healthcare is being dragged down in the wrong direction is new or at least within the past decade is just not accurate as was already documented in the previous article. On top of that, and to be clear, that somehow President Obama and the Patient Protection and Affordable Care Act (ACA), better known as ObamaCare, or HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) are to be blamed for this mess is NOT accurate either.

As if not enough, the previous history alone exonerates President Obama from healthcare’s current decline of almost half-a-century. However, for those who insist here is the record. HCAHPS showed up on the radar in 2002, a year in which one Barack Obama was not known, other than in Illinois, if that, where he was a state senator. Even in October 2006, when HCAHPS was actually implemented, there was still no Obama on the scene. And although the first HCAHPS reports were reported in March 2008, three months into President Obama’s first term, those results were from the previous administration.

By then there was very little, if anything, any new President, regardless if Obama or McCain or even Washington or Lincoln, could have done as the wheels to HCAHPS had long been spinning and there was no stopping them. Not to mention, healthcare insiders supported the IDIOT-OLOGY [sic] of HCAHPS believing HCAHPS would be healthcare’s much-needed savior following the masses not realizing sometime the “M” in masses is silent and why they followed the "asses" instead. OrFOR THOSE BORED THUS FAR, were healthcare insiders just trying to break free from outsiders who had taken them down the wrong tracks? Or, AGAIN, FOR THOSE BORED THUS FAR, had insiders finally grown a spine embracing HCAHPS just to oppose outsiders who challenged HCAHPS. As outsiders claimed HCAHPS was passé when it came to rating the experience (NEW TERMINOLOGY) at the bedside (a high-impact healthcare industry sentimental terminology/keyword depicting that the attempt was about "caring and compassion" related to patient care. Thus, the chosen word, "bedside". BALONEY! If you were to ask me. But then what do I know?).

Now, what no one has realized was that the wheels spinning was not in motion, neither forwards or backwards, but instead spinning in place. Because as of yet, 2016, HCAHPS still has not improved anything. But neither did the management IDIOT-OLOGIES [sic] like luxurious lobbies, valet service, or placating to patients, oops, customers, to mention but a few. None of the listed have improve anything during the 30+ years of chasing satisfaction scores before HCAHPS either. Meaning, neither have improved anything in the sense of the cost or quality of healthcare—the intent of all those IDIOT-OLOGIES [sic] implemented to improve the customer experience as sold to healthcare workers and the public.

I realize that stating that nothing has improved seems like an exaggeration as to what has improved or not. But when healthcare administrators are asked to list a SINGLE, yes, JUST one, “UNO”, “EINS”, a SINGLE achievement of ANY customer service implemented strategy healthcare administrators are baffled and unable to name a single example. Try it yourself. Name one single thing or ask an administrator to name one single thing, other than customer retention and/or profits, that rating healthcare has accomplished or could be credited with.

If so, add that single achievement in healthcare from chasing customer satisfaction scores in the comments and lets begin that conversation.

Interestingly, no one has ever asked, that I know, of improving access to healthcare as improving access was NEVER an intent of customer experience initiatives. Not in the 80’s, 90’s, or the new millennium, 2000 was improving access ever considered as a customer experience initiative. At least not a goal until 2008. That credit, unequivocally and hands down, does go to President Obama’s ACA and NOT to any healthcare administrator. As it was President Obama whose intent it was to increase access to healthcare rather ONLY improving healthcare’s cost and quality, but that is a separate topic.

That said, in 2008 President Obama did get involved, as just mentioned, with different intentions rather the slippery slope that had been of placating to patients, which led to HCAHPS initially. That said, in 2008, rating healthcare than moved from placating to patients to the federal government betting against healthcare.To critics, in no manner is this about President Obama, as I doubt the outcome was intentional, but instead this is about the slippery slope healthcare’s altruist, submissive and accommodating culture permitted. Because as long as healthcare continues to be a doormat not only will others walk all over us, they will wipe their feces-covered feet on us as well.Unsure, that is me unsure, but just to be clear before my words are misconstrued, whether the intent or not, but hard to believe it would be, in 2012 HCAHPS was included as 30% among the measures used to calculate value-based incentive payments in the Hospital Value-Based Purchasing program (VBP), which indirectly pays for ACA. I say indirectly only because participating hospitals forfeit, rather than pay, as much as 2.0% of their annual Medicare/Medicaid returns from not meeting HCAHPS’ EXAGERATRED UNREALISTIC EXPECTATIONS—the loss: $800,000 per average hospital, likely per year as HCAHPS’ expectations are almost unobtainable. Regardless, even if a single year, a significant savings for Medicare/Medicaid although not really a savings but instead money not paid out for services already rendered. Not because of poor healthcare but because of poor customer satisfaction scores.

Is anyone paying attention to this?

Yet, in every other industry the customer pays for the service rendered and if a customer service issue arises than that issue is resolve in some other manner, but the customer does NOT get to withhold payment for a service already rendered in any industry except healthcare. Meaning, in the retail industry if you are not happy with a nail clipper (item chosen at random without reason) you could get your money back but you cannot keep the nail clipper too.

Having said that, I might have to shallow those words because some AS SEEN ON TV products might let you keep both, the substandard product and the money. But I believe, in those cases, that product and revenue loss is already part of the gimmick. But what do I know; I AM A NURSE not a businessperson.

That mentioned there is a healthcare organization that has implemented a money-back guarantee policy. However, that policy is in its infant steps and it is too early before an evaluation can be assessed to determine its impact. Making it a follow-up story for five-years down the road.

Now diverting away from the VA and Secretary McDonald, as the VA is a non-Inpatient Prospective Payment System participant not included in VBP and may or may not voluntarily participate in HCAHPS (this point might be incorrect, however, whether the VA participants in HCAHPS or not is truly irrelevant to the rest of healthcare). Only mentioned because if so the case, that the VA, military hospitals and Indian Health Services do not participate, is it not convenient that federal healthcare does not have to participate in a program created by the federal government. But, again, another topic as well.

Nonetheless, the intent from outsiders is to control the process. Outsiders mentioned because since HCAHPS was instituted more outsiders than previous have emerged and the previous ones have adapted. In other words, more of the same just differently because when federal regulations are made more common than not a new industry emerges to circumvent the new regulations. How convenient?Thus more of the same in the sense of profits and once again neither the cost nor the quality of healthcare improves. Not that there is anything wrong with profits except that is NOT how it is sold to healthcare workers or the public. By the same token, different from other attempts to fix healthcare in the sense that now rating healthcare has two new goals—profits and access. And whether known, recognized or intended to either the goals are counter productive.Or as college leaders pointed out when the federal government suggested a similar rating system for colleges and universities. College leaders pushing back and pointing out the rating system was, “misguided…uncharacteristically clueless…quite wrongheaded…oversimplified to the point that it actually misleads and prioritized moneymaking”.

All predictable and have been actualized in healthcare, not only with HCAHPS but with the private rating systems before as well.

That said, on one hand ACA is trying to expand access, not that there is anything wrong with that either and is even commendable of President Obama extending healthcare to all. I too wish everyone had access to healthcare, maybe even free, a la Bernie Sanders. Except most of the effort in healthcare is simply wasted as so many chose not to participate in their own healthcare until the battle is ALL-uphill and by then is when it is costly. But that is another topic as well. As is a la Bernie Sanders' healthcare, as that is not the system we have thus we must operate within the one we do have.

In the opposite corner to expanding access is the healthcare customer experience, which is rated by HCAPHS. As already pointed out, although initially intended on improving healthcare’s quality and cost now HCAPHS is ALL about customer loyalty, which is ALL about profits. Thus causing pause as to if that was and is the hidden agenda. Again, not that there is anything wrong with making money except that is NOT how it is sold to healthcare workers or the public. Unless what happened was that those looking to make a profit hijacked the good intent of others.

That said, counter productive because HCAPHS and its predecessors, Press Ganey and others, have not done anything to improve healthcare’s cost, quality or access but instead set off a survival of the fittest competition as to who gets to keep their doors open. In doing so they have all left behind a significant trail of collateral damage.

Again, is anyone paying attention?

As already mentioned by college leaders these rating systems are “misguided…uncharacteristically clueless…quite wrongheaded…oversimplified to the point that [they] actually [mislead] and [prioritize] moneymaking”. Again, none of it new and not only predictable but actualized in healthcare before HCAHPS and since HCAHPS yet we continue down the same slippery slope.

So then, comparing healthcare to Disney is not such a bad an example when the previous comparison of healthcare, the VA or NOT, was that of healthcare being compared to being “Just like a waitress”. NOT only by outsiders but by insiders chasing customer satisfaction scores as well!

Sixteen years since the thought of HCAHPS in 2000. Fourteen years since HCAHPS first appeared on healthcare’s customer satisfaction radar in 2002. Ten years since HCAHPS was implemented in 2006. Eight years since HCAHPS’ first data was reported in 2008. Four years since HCAHPS took on a much different role in 2012. Nothing has improved. Not cost. Not quality. And even President Obama’s attempt to expand access to healthcare has not materialized.

Sure, some 20 million were added to the roles but that was ACA not HCHAPS. But at what cost when so many healthcare organizations have to close their doors because they are not able to keep up with the competition—not because of poor healthcare but because of the cost in trying to keep up with the “Jones” next door. And those barely keeping their doors open are spinning their wheels in place. Because after being reimbursed at a lower rate those with less-than-stellar scores will rashly spend their money to correct their HCAHPS inefficiencies rather than improving their product, healthcare.

As if not enough, the decrease in healthcare organizations and the increased access to healthcare lead to deplorable circumstances and catastrophic outcomes, like increasing medical errors, increasing wait times, increasing treatment delays and increasing nursing workloads.

Despite all the above, since the 1980’s, when the new frontier in healthcare—healthcare service excellence, was first seen as the cure to improving healthcare’s cost and quality, neither has improved. Despite all of that and nothing to show pundits continue to believe that although healthcare is broke it only needs tweaking. WHAT!?! At what point will those so-called subject matter experts will confess that healthcare is NOT broke but instead as intended, profits, profits and profits. Again, not that there is anything wrong with that but that is not how it is sold. As I am sure if healthcare workers or the public were told those were the intentions, profits, profits, profits, only then would healthcare workers and the pubic be up in arms. But as long as they are deceived that healthcare pundits are trying to fix healthcare both healthcare workers and the public will go along with it.

We need change. NOT any change as we have already tried that many times over and as Albert Einstein warned us, 

“We cannot solve our problems by using the same kind of thinking we used when we created them.”

Meaning, we must rid ourselves of traditional thinking to create the future. The first step in that direction would be to no longer NURTURE this mistake of rating healthcare JUST because we spent a lot of money, time, and effort making the mistake.

For this insanity to end we must abolish HCAHPS, along with all the other entities rating healthcare, and deflate everything customer service to nothing more than a byproduct of healthcare rather its driving force.

In order to take healthcare back we need leaders with the testicular fortitude of going against the grain, even if alone. Leaders willing to steer healthcare in the right direction, where healthcare and healthcare workers come first and away from idiotic scripts and signage, standard uniforms, valet services, luxurious lobbies, and placating to those who make demands on us.

Leaders that will promote healthcare workers as valuable and trustworthy over concerns patients will take their business elsewhere.

Leaders that will place clinical outcomes and those responsible for those outcomes, healthcare workers, first.Leaders that will ensure the safety healthcare workers and patients.

Leaders that will side with loyal employees and coworkers over outsiders, the petulant, unreasonable, angry, demanding and those who tread on us for us not submitting to their EXAGGERATED UNREALISTIC EMOTIONAL EXPECTATIONS.

Leaders who will get rid of the IDIOT-OLOGY [sic] that patients are customers, clients or guest when patients are more important then that, they are the ill and injured.

Aside the bold leaders needed we need bold companions as well, across healthcare, to stand in solidarity as the time for conversation has LONG passed. Now is time for accomplishments NOT more accommodations. Anything short of that results not in fatigue but in frustration as no one fatigues from helping others.

I know that I am not alone in these thoughts and why I ask, don’t judge my words. Judge my intent.

“Now you know the rest of the story." Paul Harvey


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