The 4AM Wake Up Call.

My friend was in the hospital a few weeks ago, nothing serious, a precautionary measure more than anything. I went to visit her and we sat and chatted. I always ask people about their experience. “What’s going well, what would you change?” At first, you hear a lot of kudos. “Everyone has been really nice.” I don’t doubt it. But, you can’t improve on compliments. I’ve found you have to ask people at least three times to get the juicy stuff.

“Well, I don’t understand why they keep waking me up at 4 AM to take blood. Is my blood only good at 4 AM,” she joked.

I know why they do it.

In The Accidental Mind, David Linden talks about the evolution of the human brain in Gladwell-like simplicity. He says evolution didn’t just pop out this perfectly coordinated mass of nerves and synapses. The brain, in fact, is the result of years of renovations, additions and remodels. One part developed to respond to the needs or deficiencies of another. The process of healthcare, unsurprisingly, isn’t much different.

Doctors usually want to round on patients first thing in the morning, around 7am. It frees them up for surgical cases or office visits early. When they round, they want to see the latest lab results. Lab tests take a few hours to coordinate and run. Thus the 4 AM blood draw.

It would be easy to point the finger at the doctor and say the patient is being inconvenienced to fit the doctor’s schedule. But, much like the human brain, it’s not that simple. Could the lab speed things up? How do we even get specimens to the lab, is that an efficient process? Well, that depends on who’s eyes you are viewing the process through.

Designing for experience

Designing for experience is about true customer focus. It is deeper than what we traditionally think of as customer service, which describes the way people interact with each other. Designing for experience requires an almost painfully high degree of empathy for the person using your product of service. You have to not only be willing to see it through their eyes, but also feel it the way they might. Getting to that level requires a holistic attention to detail. After all, how much of what we feel is defined solely by our verbal interactions with someone? How much comes from environment, ambiance, touch, visual details, perceptions, waiting times?

In 2001 Susan and I were living in Paris. No, there are no buts, it was that cool. One weekend in July started like so many others. We descended into the local metro station, Odeon, out of the sun and into the belly of Paris. After an hour of riding, including a transfer to a regional train, we began the ascent back towards the surface. The first thing we saw was a giant, antiqued sign proclaiming our location to be Main Street U.S.A. It was utterly surreal. On one corner was a 1950s themed ice-cream parlor. Across the street was a video arcade. There was even a mini Statue of Liberty. Somewhere in the distance Its a Small World After All was floating through the air.

At that moment, we weren’t in a field outside of Paris, we weren’t even in France. We were in Disney’s world. We were 12 years old, wide eyed and ready to run through the park at 100 miles per hour. They had gotten every detail right. The writing on the street signs, the food vendors, even the rides. It was a classic Disney experience.

Disney is a master of designing for experience at its resorts. That’s not a young French girl playing Snow White. It is Snow White. That’s not a facade in front of a concrete building, it is an honest old-time ice-cream pallor. It has to be, because if we saw behind the curtain, if the magic were revealed, then our brains would instantly unplug from the illusion and we’d feel like we were, in fact, in a field outside Paris, or marsh outside Orlando.

The challenge with designing for experience in healthcare, and probably most businesses, is the historical precedent of designing by censuses and compromise. Politics have become part of our corporate culture. If we do X, does it upset the person in charge of Y? If so, what is the compromise? And there’s the rub. When we compromise to satisfy internal politics or business pressures, more often than not, we are making an even bigger compromise for the patient. It’s how we get the 4 AM blood draw.

The PocketPC and importance of the foot fetish

In 2002, I had a PocketPC device. Its marketeers clearly took liberties with the size of the average pocket, but nonetheless it was a fairly compact thing for the time. It had a stylus-based touch screen, miserable handwriting recognition and very limited Windows PocketPC software. But, I like to live on the cutting edge with gadgets, so I picked one up.

What I really wanted was to watch movies and TV shows while at the gym. The problem was that it used some obscure file encoding. Not only that, the videos had to be perfectly formatted for the screen size. I found that if I ran a video through two different programs on my desktop PC, I could manipulate the file enough that it would usually play on the PocketPC.

I was the only one at the gym watching their own personal video screen.

I’ll never forget the reaction of a friend who saw me on the elliptical one day: “you really are a huge nerd aren’t you?” It was a friendly jab. At least I think it was. Fast forward to today, almost every runner on a treadmill has an iPod, iPhone or small personal device. This morning I saw one musclebound guy in a weight belt and tank top entering reps onto his iPad which he carried with as much pride as his protein shake. I dare you to call him a nerd.

What once was once a niche use case, is now the norm.

This summer, at Stanford’s Medicine 2.0 conference, the precursor to the recently announced Medicine X series, Dennis Boyle from IDEO spoke about design thinking. He flashed up a slide of a stocking clad leg disappearing into a bright red high heel shoe. “If you want to make the best shoes, ask someone with a foot fetish to review them, they know more about shoes than you do,” Boyle told the audience. What a line!

The past few years have given rise to a new term, e-Patients. These paradigm changers are empowered, engaged, informed, and most of all, desiring to participate in their care and planning as an equal peer. An e-Patient can be someone who googled symptoms before going to the doctor, or someone who studies their lab results with the veracity of a Rhodes Scholar.

The Pew Internet and American Life Project reports, “one in five Americans have gone online to find people with similar health concerns.”

Still, not everyone one is convinced. One doctor privately quipped to me, “thats just what we need, more people using Dr. Google.”

I understand his reaction. The perception is e-Patients come with inaccurate information, too many questions, or have unrealistic expectations of a doctor’s availability. That misses the mark. The value of e-Patients, in addition to arugably reducing the burden on providers, is as the extreme use case. What if they are high-contact and high-need? Embrace it. They are the early PocketPC users who can tell you why using two programs to put videos on a device is seriously flawed. They are the ones with a foot fetish who can tell you why that color red isn’t ideal.

They are the ones who can tell you why a 4 AM blood draw is not a good idea.

Facing the future

Designing for experience in healthcare requires a wholesale change to the way we plan for and implement services. Rather than design by committee, teams need to focus on putting themselves in the patient’s perspective. If you want the ideal inpatient blood draw, sleep in a hospital room, and have someone wake you up at 4 AM two days in a row. By the third day, you’ll have some creative ideas for solving the problem.

Boyle suggested being pushed around your hospital in a wheelchair, not once, but hundreds of times. See if from the eye level of someone sitting down. You’ll notice how most nursing stations have counter tops higher than the eye level of someone in a chair. A hospital CEO once remarked to me, “you know it doesn’t really matter what art we put on the walls, all of our patients are laying down and only see our drop tile celling, and man is it ugly.”

Designing for experience also requires a high degree of empathy for the customer. It means you have to open yourself to feeling what they feel. Imagine being scared or confused or sedated. Empathy means thinking about what you would want in the same position. Have you sat waiting for 45 minutes in a doctor’s waiting room? Do you like it? Then why do we think our patients will. There are solutions to these problems, but they require us to design for the patient experience, not the personal or political needs of the organization.

If you think designing for end user experience comes at a high cost or the sacrifice of revenues, just look at Apple’s current market valuation. It can be done.

Designing for experience also means embracing the fringe use cases. Look towards our most frequent users, our e-Patients or our squeakiest wheels. What can they tell us about what works and what doesn’t? What feels like fringe today will probably be the mainstream of tomorrow. Do we want to be ahead of it, or behind it?

Experience is a differentiator. In describing my experience at Thomas Keller’s restaurants in this post, I said I expected the food to be amazing; it’s was a given. What makes the meals memorable are the experiences. It is the same thing which sets Disney’s parks apart from Six Flags. The Disney visit is a complete experience. It is the same thing which has made the Ritz-Carlton a world famous brand. We make choices based on emotion first, and reason second. Emotional connections are made with experiences. We expect excellent clinical care whenever we walk into a hospital. (If it’s not excellent, we have bigger problems.) Experience makes the competitive difference.

If we want a healthcare system which works, is high quality and patient focused, we have to start designing for experience.

Ask any kid who they would list as heroes and role models and my guess is that pilots are on that list. I bet doctors are too. Ask any adult what they think about traveling or going to see a healthcare provider and their reaction may not be as awe inspiring.

If you had asked me two weeks ago if I was excited for vacation, I probably would have given a reluctant “yes”. That reluctance would have had nothing to do with how the week turned out (knee injury). The stress in my voice would have everything to do with the travel. I will admit it, six years of crisscrossing the company consulting for hospitals left me a little discontented with the airline industry. Here is the kicker, there are a lot of similarities between the airline industry and healthcare and its not because of the fares.

I am convinced, but hopefully not jaded, that airlines will always drop the ball in some regard. It may be lost luggage, a botched seat request, delayed flight, or more than likely ornery crew. Seats are littered with trash and crumbs from the previous flight. Ever walked up to a gate agent who is too busy typing to look up? Its become a cliche! What about flight attendants who roll their eyes at passengers trying to lift bags into the bins? In short, it is not an industry where many people expect world class service. A lot of the issues are surrounding the belief that airfare is the number one determining factor in how passengers pick an airline. To race to the bottom means cutting a lot of employee benefits. The Gallup organization will attest, that employee satisfaction is the key driver in providing good service.

The airline industry has had a lot of pressures that have resulted in over stressed and overworked employees. Fuel costs, decreased volumes (following 9/11) and telecommuting technology mean less people are traveling. To cut costs, some airlines have merged, filed bankruptcy and restructured. Restructuring often allows them to work employees longer hours and on less wages; not the kind of thing that makes anyone happy to serve customers. As an example, some airlines have dropped contracts with cleaning crews in favor of having flight attendants clean the cabins- all the while doing so on wage cuts. I do not offer that as an excuse for poor service, but only to shed some light on the surly attitude of the front line staff.

Ask any kid who they would list as heroes and role models and my guess is that pilots are on that list. I bet doctors are too.

What does that have to do with healthcare?
If doctors really are still our healthcare heroes, what does that make the rest of the the professionals in the healthcare industry? We have reservations, thats the scheduling department. We also have ticketing agents, we call them Patient Access. From there, it may be a little more nebulous but I suspect readers can find appropriate analogies for flight attendants, luggage handlers, mechanics and executives.

Most patients interact with the front line staff – patient access, nurses, etc- far more than they see the doctor. Frequently the interaction we get with the ‘hero’ is not much different than the overhead announcement and the casual goodbye while you deplane. That means that our front line teams hold the entire experience in their hands. Botch the reservation or roll your eyes at check-in and you have ruined the patients entire ‘flight’.

Healthcare has very similar stresses. While it may not be fuel costs, providers are struggling with lower reimbursement. In many markets Medicare pays less than the cost of procedures. The industry has built a business around group health plans making up that difference, a hidden tax on employers and patients. Other markets are facing the threat of unions who’s contracts limit what someone can and cannot do as part of their job. Ask a union nurse to take away the tray of food and you may be surprised to hear that he cannot, he has to call dietary services. Of course dietary services cannot clean up the mess, that is the role of house keeping. Not exactly a seamless service experience but probably something that sounds very familiar to unionized airlines.

How do we change course?

Barack Obama has set the tone for this generation – a time of change. His campaign may have been one of the greatest grass roots efforts in our democratic history. One of President Obama’s clearly stated goals has been healthcare reform. While I personally believe that the administration’s focus is on the payor side of the industry it does not recuse providers from examining their owe practices. (It is also worth noting that during the election Obama was the number 1 twitter user, with the most followers.)

If providers do not own their image and cultivate a service culture, then they will find themselves in the same position as the airlines. Patients may come through the doors, but they only praise they will be singing are about the ‘heroes’, the physicians. The only way to change that future is to take the reigns and effect change in how the organization presents itself. It starts with employees who want to come to work and represent you on the front line. Ask them what they need to in oder to do that for the organization.

James Gillmore and Joseph Pine, in their work The Experience Economy assert that good service is tantamount to success. Experience Economy spells out the importance that front line staff plays in giving the customer a seamlessly wonderful encounter. Like the Ritz-Carlton’s goal, providers should strive to fulfill every customers desires, spoken or unspoken. When we see someone who looks lost, stop and offer to help. Do not be the flight attendant that watches the elderly man who cannot lift his bag. If you are a physician do not be late. When passengers hear ‘weather delay’ and see blue skies, it does not matter what the true cause is; they are not getting where they want to be. This is the time, as has been discussed here before, to start connecting with all of the healthcare constituents outside of your physical walls. The tools are free, all it takes is the willingness to use them. Lets ask ourselves how we would want to be cared for, then do that!