The Customer is NEVER Right - A Nurse Practitioner's Perspective
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No other industry, NONE, has healthcare's waiting room

This began as a reply to a healthcare system administrator’s LinkedIn article about eliminating healthcare’s waiting room. To which I agree we should, need and can eliminate waiting rooms in healthcare. I have worked at one of those emergency departments where there was no waiting room. It was a Trauma Level I emergency department that was also a Stroke Center and Chest Pain Center with a census of 90,000+ annual visits and no one waited, regardless of acuity. I loved that system. WOW, did the shift fly and before you knew it the shift was over and it was time to go home, at least until the next shift. Wash, rinse and repeat.

However, I DO NOT believe any administrators' desire to eliminate the waiting room has the same interest as mine. The article’s claim is that in healthcare’s current culture patients wait because “the doctor is the most important person and everyone is on their time [and why] to be truly patient-centered, we need to get rid of the waiting room.”

Sounds caring and even compassionate, however, whenever healthcare hides behind patients it always raises flags as to what is the hidden agenda. That is why in The Customer is NEVER Right: A Nurse Practitioner’s Perspective I wrote that I DO NOT hide behind patients for any reason. Much less to obtain the changes healthcare and healthcare workers deserve. Instead I believe that change ought to be because of healthcare and healthcare workers and not because of patients and much less customers. It is healthcare workers who are sought after for their expertise and who are responsible for the world-renown healthcare we provide. Not to mention, and with reason, it is the same healthcare workers who are held responsible when things go wrong. So healthcare workers being the center of healthcare has a precedent and returning back to such would not be a bad one.

My opinion of course as we all have them but any administrator with intent to eliminate the waiting room in order to put patients first is no more than another gimmick at comparing healthcare to other industries for the sake of the customer experience. A fixation of healthcare despite studies have shown there is NO correlation between satisfaction scores and good healthcare. And worst that the most satisfied patients not only spend the most on healthcare and prescriptions but they are also must likely to be admitted and most likely to die.

But also a fixation of healthcare despite the difference between healthcare and other industries is colossal. As healthcare is the only industry with patients. The only industry in which services are sought during some of the worse moments of our lives and during inconvenient times for uncertain, unpredictable and volatile choices in places that are unknown, unpleasant and unforgiving. The only industry where regardless of disposable income or time services are sought after and rendered. The only industry whose workers maintain the public’s confidence, year after year, as the public recognizes us as the most honest profession and with the greatest ethical standard of any industry. Most notable, healthcare is the ONLY industry where workers go to battle for every “so-called customer” and when “so-called customers” succumb we cry for them as well, as the overwhelming numbers of patient experiences are rewarding for both healthcare workers and patients. But of all things, healthcare’s waiting room is one of those mammoth differences compared to other industries.

As NO other industry, NONE, has healthcare's waiting room!

All that said for the following and where the reply to this article began before it became to long to post as a reply. However, and to be clear, this reply is not intended to call out any single healthcare administrator or system. Nor is the intent to drag anyone’s dirty laundry onto the public square, as the IDIOT-ology [sic] of comparing healthcare to other industries and the obsession with satisfaction scores is not of one single healthcare administrator but the norm in healthcare. To critics, the examples cited are just that examples that are readily available and cited without malice intent. With that in mind, this reply is no more than another attempt, of the many already published, of bringing to light the damage that has been done and continues to be done to healthcare, healthcare workers, and patients as a consequence of chasing after satisfaction scores.

In healthcare we have very few leaders when defined as—leaders get others to do what needs to be done by providing purpose, motivation and direction. Instead what we have is an abundance of managers who merely facilitate policy between superiors and subordinates. A more blunt and succinct version of those differences is, managers thinking they are leaders and leaders show up to work. Ouch!

For the sake of being transparent and to be clear, I am a fan of removing waiting rooms in healthcare as I have worked in such environment and loved it. But these customer experience initiatives are no more than gimmicks as there is NO correlation between customer satisfaction and good healthcare. Sadly, despite ALL the money, time and effort allocated for these gimmicks they have done NOTHING for healthcare but leave behind an overwhelming amount of collateral damage, billions of dollars wasted and nothing to show as the customer experience needle has not moved.

Most comments/replies to the mentioned article have been accolades for this “forward and innovative” thinking administrator with regard to improving healthcare at his organization. Got it. And the attaboys are even deserving when the initiatives are glimpsed at superficially. However, when studied more in depth, this healthcare system is not only subpar with regard to the customer experience as documented by the federally mandated Hospital Consumer Assessment of Healthcare Providers and Systems [HCAHPS], which rates healthcare’s customer experience. But on top of that, it is also subpar with regard to the seven measured groups/categories used by Medicare to compare hospitals. Those seven measures being mortality, safety of care, patient experience, readmission, effectiveness of care, timeliness of care and efficient use of medical imaging.

Following are the Medicare ratings for the mentioned healthcare system’s individual organizations as of 29 Dec 2016:

Overall rating: 2/5
Patient satisfaction survey: 3/5
Patient recommendation: 75% vs state 70% vs national 72%
Value of care:
Heart Attack-No different than national rate at less than national average payment
Heart Failure-No different than national rate at less than national average payment
Pneumonia- No different than national rate at no different than national average payment
*How can the patient recommendation be 75% (above the state and national averages) when the overall rating (seven measured groups/categories) is a mediocre 2 of 5?

Overall rating: 3/5
Patient satisfaction survey: 4/5
Patient recommendation: 70% vs state 70% vs national 72%
Value of care:
Heart Attack-Number of cases too small to compare
Heart Failure-No different than national rate at no different than national average payment
Pneumonia- No different than national rate at less than national average payment
**Outlier with the greatest patient satisfaction survey within the healthcare system. However, in healthcare it is well known that facilities that are too small to rate their value of care will commonly have higher patient satisfaction surveys when compared to large facilities. The most common reason—large facilities have larger census and sicker patients and small facilities (like this one) will transfer patients they are NOT able to care for. That said, and a point that there is no correlation between satisfaction scores and good healthcare, who wants to receive care for a heart attack at a facility with limited heart attack experience despite the facility reports a 4 of 5 patient satisfaction? NO ONE!

Overall rating: 2/5
Patient satisfaction survey: 2/5
Patient recommendation: 64% vs state 70% vs national 72%
Value of care:
Heart Attack-No different than national rate at no different than national average payment
Heart Failure-No different than national rate at greater than national average payment
Pneumonia- No different than national rate at no different than national average payment

Overall rating: 3/5
Patient satisfaction survey: 3/5
Patient recommendation: 74% vs state 70% vs national 72%
Value of care:
Heart Attack-No different than national rate at no different than national average payment
Heart Failure-No different than national rate at greater than national average payment
Pneumonia- No different than national rate at greater than national average payment

Overall rating: 3/5
Patient satisfaction survey: 3/5
Patient recommendation: 51%** vs state 70% vs national 72%
Value of care:
Heart Attack-No different than national rate at no different than national average payment
Heart Failure-Better than national rate at no different than national average payment
Pneumonia-No different than national rate at no difference than national average payment
***Outlier with lowest patient recommendation (51%, lowest rating I have ever noticed since documenting these numbers). Yet has equal overall rating and patient satisfaction survey. And even Better than nation rate for heart failure patients. Yet, least "patient recommended" among the healthcare system. That low "patient recommendation" likely the cause for the lower patient satisfaction survey and consequently the lower overall rating as well. Otherwise, had it not been for the low "patient recommendation" score this facility may have been the jewel of the entire healthcare system with overall rating and patient satisfaction survey both likely being 4 of 5. Note: It is this facility's overall GOOD healthcare (seven measures total) which gives the facility its 3/5 overall rating despite the low "patient recommendation". However, it is its LOW "patient recommendation" which will keep patients away DESPITE the GOOD healthcare. Does that make any sense!?!

Healthcare System Overall (this healthcare system rating was an average of the organizations within the healthcare system as HCAHPS does NOT rate systems but ONLY rates individual organizations)
Overall rating: 2.6/5
Patient satisfaction survey: 3/5
Patient recommendation: 66.8% vs state 70% vs national 72%

The history of rating healthcare in a nutshell. For the first half of the past 30 years private companies did the rating, the most infamous of them Press Ganey. Because of the different company rating models both patients and healthcare organizations found the competing results to be confusing, unfair and failed in their intent to rate healthcare, shortcomings that lead users to complain to their politicians.

In 2006, in an attempt to consolidate and improve the rating of healthcare, the Centers for Medicare and Medicaid Systems implemented HCAHPS. Initially, “incentives” were put into place to encourage participation. However, those “incentives” were only in term, as the actions of those “incentives” were punitive from its onset and NOT motivators.

By 2012, HCAHPS would "bet" against healthcare, something private rating systems never intended or did. The purpose of HCAHPS versus healthcare was and continues to be to offset the cost of the Affordable Care Act (ACA) (before the objections this point is neither against President Obama or ACA, as I too wish healthcare were free to ALL but that is not the system we have). To do so HCAHPS’ “incentive” tentacles would strangle organizations with less-than-stellar customer satisfaction scores by withholding Medicare reimbursements from those organizations—actions that undermine the survival of those organizations after they are unable to keep up with chasing after satisfaction scores. Making matters worse, after being reimbursed at a lower rate a low-performer will rashly spend its money to correct the customer service inefficiencies rather improve its product, healthcare.

This is where the mentioned healthcare system possibly finds itself, as the organization’s “money-back” guarantee incentive has not bore fruit for the organization since its commencement November 2015. An incentive I found not as visionary, when I first read of the announcement, but instead believed the incentive would be the organization’s demise but to which only time would tell. However, to date the system has “lost” $500,000 in the first year of the money-back guarantee refunds. That said, the average “loss” in Medicare reimbursements from failing HCAHPS’ expectations is $800,000 per year.

This IDIOT-ology [sic] of throwing money, time and effort to improve customer satisfaction scores before improving your product, healthcare, only results in a vicious cycle of losing money. As the IDIOT-ology [sic] fails to fix any problems and makes them worse as many of these organization eventually close their doors or loose to the merger of a competitor within the same market. Consequences which commonly are followed by a domino effect of overwhelming collateral damage as now that organization’s patients must go to "Elsewhere Medical Center", where overcrowding leads to deplorable circumstances and catastrophic outcomes, like increasing wait time, increasing treatment delays, increasing nursing workloads and increasing medical errors to name a few.

In addition to those already mentioned here are additional examples of the collateral damage left behind because of healthcare’s obsession with rating healthcare and why rating healthcare is NOT good for anyone, not for healthcare, not for healthcare workers and worse for patients.

-“Perverse incentives” (as Iowa US Senator Chuck Grassley labeled HCAHPS’ “incentives” during a Senate Judiciary committee hearing about opioid abuse on 27 Jan 2016) [my addition] that NOT only lead to improper opioid prescriptions, and indirectly their abuse, but those “perverse incentives”, without doubt, are the cause of inappropriate admissions, diagnostics, procedures and other improper prescriptions as well.

-In 2011, the Centers for Medicare and Medicaid Services (CMS) spent $226 BILLION on overtreatments that did not benefit anyone. How much of that to avoid complaints from patients?

-That $226 billion wasted does not include the BILLIONS lost as a result of healthcare directed violence, a violence that has become more frequent, more brazen and more violent. Those statistics skewed, as we fear losing our jobs and why negative incidents are underreported. Isn’t it sad the industry on the forefront of fighting domestic violence finds itself in an abusive relationship, to include justifying the violence and siding with the actions of those who are abusive towards us?

-Anecdotally, it is that misery and frustration which drags us down, as we must navigate, ALONE, that exhausting minefield just to say safe and/or keep our jobs. Reason enough as to why so many leave healthcare and NOT fatigue as NO ONE fatigues from helping others.

On top of ALL that, despite all the money, time and effort wasted on rating customer satisfaction the needle has not moved. That's not just in healthcare. In Feb 2015, Rick Conlow, a customer experience guru, posted an article on LinkedIn titled “The great customer experience scam” where Mr. Conlow pointed out, “You would think customer service should be getting better, with all of the surveys that are done and all of the new technology. Plus, there was the quality service revolution the last three decades [1990-2010]. Billions of dollars were spent. Right? Wrong!”

Interestingly, healthcare administrators and pundits already know ALL of this.

None of this is breaking news as it is ALL public knowledge. The literature, both professional and lay, is inundated with articles that list a plethora of reasons as to why rating healthcare is NOT only bad for healthcare, healthcare workers, and patients but it is a slippery slope as well. But no one is interested and healthcare administrators and pundits chose to follow rather than lead, citing, "That is what they are doing up the street and so will we." None of them having the testicular fortitude of going at it alone.

Is taking healthcare back possible? ABSOLUTELY!

Because of the idiom, “It’s easier to fool people than to convince them that they have been fooled,” taking healthcare back will be a challenging battle. The reason, healthcare administrators and pundits are influenced by outsiders who have led them to believe that “the train has left the station, so either get on or be left behind as customer satisfaction scores is where healthcare is headed”. Sadly there is no one opposing that groupthinking despite the train is headed on a collision course as the IDIOT-ology [sic] of accommodating the EXAGGERATED UNREALISTIC EMOTIONAL EXPECTIONS of a few is not sustainable.

Plagiarizing Albert Einstein, “Healthcare will not be destroyed by those who take it down the wrong tracks but by those who watch them without doing anything.”

However, there is hope. In 2013, the federal government announced a college rating system, with intent similar to HCAHPS, to withhold billions of dollars in federal student aid money from low performing colleges. However, thanks to college leaders who, unlike healthcare, stood their ground and pushed back that college ranking system was abandoned. In pushing back those leaders pointed out the proposed “misguided” rating system was “quite wrongheaded…uncharacteristically clueless…oversimplified to the point that it actually misleads [and] prioritized moneymaking”. All predictable and have been actualized in healthcare under HCAHPS and with its private predecessors as well.

It is all too common to hear that we spend too much on healthcare. How can we not? Healthcare is our lives. However, the issue is not that we spend too much on healthcare but that we WASTE too much IN healthcare. Because of that waste, to include that wasted on HCAHPS and chasing after satisfaction scores, our great nation’s healthcare system is in crisis, a silent crisis as so many choose to look away.

Just to be clear, this tolerated and largely ignored silent national crisis is not political as we only have healthcare’s submissive, altruistic and accommodating culture, and its obsession with customer satisfaction scores to blame. Not only did we follow the herd but we turned over the reins and since outsiders have taken healthcare in the wrong direction with their IDIOT-ology [sic] that it is in the patient’s best interest.

After NOT improving a single statistic with regard to patient outcome or the safety of healthcare workers or patients and failing us ALL for so long the time for conversation has long passed. Now it is time for accomplishments NOT more accommodations. Because of that I suggest HCAHPS be abolished and healthcare customer satisfaction deflated to no more than a byproduct of healthcare rather its driving force. ONLY to be replaced by putting healthcare’s best product forward, the healthcare worker. The evidence for this exciting seismic paradigm shift—more than 30 years have gone by of chasing satisfaction scores only to have more expensive and not better healthcare. Not to mention, NO ONE, not ONE healthcare administrators or pundits, can list a single achievement of chasing satisfaction score over the past 30+ years. NOT ONE achievement! NOT ONE! Other than customer retention and profits, which I know we can achieve, and then some, if we put healthcare workers first.

Lastly, 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. That includes, just to begin with but not limiting ourselves to, we MUST no longer NURTURE this mistake of rating healthcare JUST because we spent a lot of money, time, and effort making the mistake.

We MUST take healthcare back! But, what if the current healthcare system is not broke but instead as intended—focused on customer retention for profits and the customer experience is just a ploy for those desired goals?

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