Maurice A. Ramirez, DO, CNS, CMRO

Did We Ever REALLY Ask?

Hospitals and their corporate officers live and die by customer satisfaction scores such as the Press/Ganey Survey and Harris Poll. The problem is that these “surveys” & “polls” are little more than “opt-in” commentaries. Scientific data shows that, regardless of industry, a dissatisfied customer is three times more likely to express their opinion than a satisfied customer. Given this fact, the healthcare industry standard “opt-in” model, by its very nature, should yield a 3 to 1 dissatisfaction bias. Given that this bias is not seen indicates that other, unaccounted for factors, are skewing the data.

Survey Construction
To obtain meaningful data from a survey or poll, specific criteria for data collection must be met. The first and most important is that the demographic make-up of the study group must be determined before the data is collected. Demographics includes more than gender, age and ethnicity. In the healthcare setting, treatment area specific identifiers such as time of year, triage level on presentation (ESI 1-5), initial evaluation and management level (E/M 1-5), waiting room wait time, length of stay, etc. allow for further differentiation of individual factors influencing patient sentiment and satisfaction.

These demographic groups must be strictly adhered to and once the number of a particular group is obtained for a given survey, no further survey responses are accepted in that demographic group. Further, if a particular demographic group is not fully enrolled with respondents, additional individuals are recruited in that demographic group only until the required number of responses are obtained. This is currently not done in healthcare, yet it is the key to obtaining interpretable data.

Questions Are Key
In healthcare, the rule is to ask open ended questions to obtain global information and then ask close ended questions to obtain specificity. In survey construction, specific questions must be asked before the survey is constructed. Like a scientific investigation (and all valid surveys are scientific investigations) the first question is to ask what specific and narrow question we seek to answer. Commonly, the response from corporate leaders is that they want to know if customers are satisfied, but this is not sufficiently specific. Which customers? Under what circumstances? Such a customer satisfaction question would be,

“Are customers with an ER lobby wait of greater than 4 hours (all other demographic factors being equal) more satisfied customers than those with a lobby wait greater than 4 hours?”

Once the question is narrowed to a specific single area, a null question (null hypothesis) must be formed. This is a testable question such as,

“Is there a difference between customers with an ER lobby wait of greater than 4 hours (all other demographic factors being equal) and those with a lobby wait greater than 4 hours?”

This latter question can be answered easily by having a demographically specific and identical group score their satisfaction then dividing them based on their lobby wait time. A simple comparison of the satisfaction scores between the two groups will then indicate the influence of lobby wait on satisfaction. Obviously, those with different demographic factors will respond to wait times differently and thus narrow demographic groups with large numbers must be studied to determine if lobby wait is in fact a factor at all.

Acknowledge Framing Bias
The construction of a survey or poll must also include a consideration of the bias held by those asking the questions. Failure to acknowledge even seemingly unrelated bias will inevitably skew the results due to the framing of the question. Referring back to the ER lobby wait example above, most in healthcare leadership hold the belief, based only on unscientific “opt-in” commentaries, that ER lobby wait is a key factor in customer satisfaction for all ER patients (regardless of other demographics). This bias results in customer satisfaction studies that are skewed to elicit comments congruent with that bias such as,

“Was your ER wait time short, adequate, long, excessive?”

This question primes the reader to view a long ER wait (even for a non-emergency) as excessive if it is longer than they wanted. The unbiased approach would be to determine ER wait time as a demographic factor based on the time from sign-in (arrival) to the time place in a room (door to room time). Having this information, the question would then be,

“Please rate your overall satisfaction on a scale of 1 through 5 (1 = very dissatisfied & 5 = very satisfied)”

The statistical comparison of overall satisfaction between those with an ER lobby wait under 4 hours and those with a wait over 4 hours within otherwise matched demographic groups yields an accurate reflection of the impact of ER lobby wait on overall satisfaction.

Bad Questions Yield – Bad Conclusions
Just in case there is any doubt of the influence of bias, an “opt-in” commentary invitation was placed on the internet for seven days and circulated using a professional networking service.[1] An analysis for power determined that 53 respondents were required for statistical significance.¹ Like all healthcare customer satisfaction surveys currently employed, any person having been an ER patient was included in the final analysis.¹ Over 28,900 individuals viewed the question, but only 59 “opted-in” with responses.¹ A heuristic analysis for bias was preformed to generate a question that minimized bias based influence on responses.¹ The resultant question asked,

“Given that your wait in the lobby and your total time in the ER would be unchanged, would you rather have your ER doctor come into the room 10 minutes after you are brought from the lobby to introduce themselves but do nothing else, or would you rather have your ER doctor come into the room 25 minutes after you are brought from the lobby and complete the entire interview, exam and ordering of tests/treatment?” ¹

The 10 minute option and the 25 minute option represent the current ER incarnations of LEAN and Six Sigma respectively. Pre-study review of the ER management literature found that the majority of the responses would prefer one of the other, but there was no consensus on which option would be preferred.¹

Surprisingly, out of 59 responses, 1% offered no preference, 53% preferred the 25 minute wait and 46% preferred the 10 minute wait.¹ Of greater interest, one in twenty of those who preferred the 10 minute wait stated that they only preferred it because they could “bully” the doctor into staying and completing the entire patient encounter rather than leaving after the introduction.¹ Despite respondent reframing of the options, there was still no statistically different difference between the options.¹

While each of these approaches have ardent supporters who insist that their approach is the solution to low patient satisfaction, this data suggests that the right question has not yet been asked and thus the true answer has not yet been found.

Asking a Better Question – Getting Better Answers
Asking better questions often yields surprising and useful information. Markoul, Zick and Green published a survey based study looking at how patients prefer to be addressed when they first meet their healthcare provider.[2] In most healthcare encounters, physicians greet patients by either first name or title with last name while introducing themselves with their title and last name. Conversely, nurses are taught to great patients by first name and introduce themselves by first name only. Across the board, all healthcare providers are counseled to offer a handshake at every encounter.

Answering closed-ended, narrowly constructed questions, a survey of 415 patients found that 50% the patients wanted their first name to be used when physicians greet them.² Similarly, 16% of patients preferred to be greeted by their title and last name, and 24% wanted their first and last names to be used.² As to how healthcare providers should introduce themselves to the patient, 56% wanted to hear both names; 33% wanted the provider to use just their title and last name, and only 7% wanted first names to be used.² Approximately 78% of respondents expected to receive a handshake, with older patients less likely than younger patients to want a handshake (74% vs. 87%; P < .005).² 

This data shows that the broadest group of patients would be satisfied if their provider greeted them using first and last name names (satisfying all three groups). Further, providers should introduce themselves using title with both first and last name while offering a handshake (again satisfying all groups).

Getting to the Answers Needed
Patient and customer satisfaction surveys are a fact of life in the business of healthcare. Improving these critical business benchmarks is too often linked to hastily contrived and implemented process changes. If the key to making the best decisions is having the best information and the key to having the best information is asking the best questions to the right groups of people, then before the next survey is sent out, healthcare must create better surveys.

• Determine the distinct demographic groups to be surveyed
• Determine the exact number from each group to be surveyed
• Survey exactly that number from each group (no more and no less)
• Determine the question to be answered and the null question to ask
• Acknowledge framing bias and frame the null question without that bias
• Limit conclusions to the answer for the null question
• Use inconclusive results as a guide to identifying factors without influence on customer satisfaction
• Use conclusive results as a guide to identifying actions that will improve customer satisfaction

When healthcare really asks patients for the answers it seeks, customer satisfaction scores will become irrelevant because patients will automatically get what they need and deserve.

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[1] Ramirez, M. (unpublished data)

[2] Makoul G, Zick A, Green M. An evidence-based perspective on greetings in medical encounters. Arch Intern Med 2007;167:1172-1176.

Globalization and Generation Y

The international marketing firm Youngster recently reported that for the first time in history, the market group known as Generation Y, those ages 10 to 25, is evenly divided across each of its five age based subgroups. A short to ten years ago when Generation Y first burst on to the scene, the vast majority of Generation Y was age 10 to 14. This first wave of Generation Y influenced popular culture giving us nSync and Brittney Spears.

The youngest segment of Generation Y represented over 50% of the group and they controlled the mass media market. In the 10 years that have followed, the early 10-year-olds of Generation Y became 20-year-olds filling out the top ranks of Generation Y. The relatively constant birth rate in the Western World resulted in an even distribution across all stages of the Generation Y.

The expanding size of Generation Y has resulted in the dissemination of their influence not only through popular culture as determined by those younger than 18, but also the business culture that is determined by the most innovative in the technology field, those age 18 to 25.

But, what impact will this have on globalization?

To understand the influence this group has, you must understand how Generation Y functions.

The First Digital Natives
Generation Y has been referred to as the first humans native of the digital landscape. This means that a Generation Y has never known a world that did not include the internet, cellular phones and immediately available parallel communications. All who came before Generation Y are no more than digital tourists, but Generation Y is as comfortable and capable in the digital world as in the physical world.

Any parent of a Generation Y teenager has marveled as their child adeptly talks on their cell phone, often on a three-way call, while sending SMS text messages and sending email directly from their cell phone. These amazing youngsters do all this while playing online RPG’s (role playing games) that combine video, audio, and text conferencing. An amazing six simultaneous lines of communication involving 30 or more simultaneous participants that demonstrates how Generation Y has evolved the very concepts of networking, collaboration and community.

The RPG player must learn and master no less than 70 new rules or skills. These 70 skills do not increase the player’s likelihood of success in the game, rather these 70 skills are the bare minimum to negotiate the first level of the game. To advance through the game requires the monitoring of no fewer than 100 individual incoming streams of data from 360 degrees in all three planes of three-dimensional space (X, Y, and Z axis). In addition, the most recent generations of game systems allow players to collaborate in real time with individuals not only within their country but across the internet in other countries.

These collaborations are not bounded by language differences. As a result, to work collaboratively within a given group and have that group work collaboratively against other groups, the players must learn either a language unique to the game or one utilized in common by all players within their team.

Neighborhood Y
Generation Y members utilize services such as MySpace and Facebook to serve as their digital homes. Similarly they use professional networking services such as Xing, LinkedIn, and Konnect as their digital offices. For a member of Generation Y, Facebook is a home in their personal neighborhood, while MySpace is their bedroom. It is not unusual for Generation Y individuals who initially met in a professional environment to exchange Facebook and even MySpace contact information to facilitate a larger social interaction.

Even more indicative of this tidal change is the number of Generation Y relationships that begin as personal social exchanges only to evolve into professional relationships and even business collaborations. Generation Y professionals don’t believe in going it alone. Spouses will get to know each other having never met face to face. Children will play video games and even together learn in simulation enhanced learning environments.

xBox Education
What would happen if the much ballyhooed No Child Left Behind curriculum were handed over to video game programmers and utilized as the rules, processes and systems of a series of role playing adventure video games?

• The entire K through 8 curriculum mastered in two and a half years!
• Four years of high school completed within 18 months.
• Completion of the first two years of college by the end of eighth grade.
• Recall and application in excess of 90% accuracy and proficiency.

The problem with the application of such a model within our current educational system is that for Generation Y, the RPG is not technology, rather it is a tool while for those who provide education, RPG systems represent what was once considered a “super computer”. This is a chasm almost too wide to forge.

World-Y-Business
As Generation Y, moves from their current position as entry-level managers to corporate leadership, they will bring with them these networking skills. LinkedIn is their North American office, while Xing is their European branch office and Konnect their Asian branch office. It is not unusual for a Generation Y professional to have over 10,000 direct first person contacts developed through Web 2.0 and Web 3.0 networks. This is not a collection of random business cards, but rather individuals with whom they have developed business and personal relationships, even friendships. These professionals not only discuss business ventures, successes, and failures, but seek each others advice in open mentoring opportunities and even share personal feelings in these virtual spaces.

These young professionals have truly tapped a globalized market through the use of the internet and social networking services. The only question, is the global market ready for true globalization?

Entrepreneur Heal Thyself

As the practice of medicine becomes more and more the business of medicine physicians find themselves with an ever widening view of the market based world. Some physicians retreat into practices where they need “only practice medicine” and allow others to “deal with the business side.” Other physicians choose to “take the bull by the horns” and manage their own enterprise. Others choose to diversify their entrepreneurial interests. Physicians who move from the entrepreneurial world of running a medical practice to non-clinical entrepreneurism fall into two categories:

First are those that find a non-medical outlet for their entrepreneurism. These physicians often really want out of medicine, but have spent a career contributing and do not want to feel that they no longer matter.

Second are those that find a medically allied entrepreneurial endeavor that allows them to use their hard earned knowledge and skills to support themselves without the problems and challenges of direct clinical practice.

Physicians in each category often continue to practice medicine either to supplement their income, or because the financial freedom provided by no longer depending on medicine for financial security now allows them to make the decision to practice thus restoring joy to medical practice. 

Paging Dr. Experience
The entrepreneurial life of running a medical practice is much the same as that of running a start-up business. The only significant difference is that a medical practice runs on a larger budget initially, but a smaller budget and profit margin later on. Non-medical start-ups usually begin with marginal funding and, if successful, grow as their income grows eventually reaching a point where their budget and profit margins are both quite respectable.

Because of their leadership role in healthcare, physicians are drawn to business leadership and executive positions. When it comes to physician executives, there are two types of “CEO’s.” Those whose lives present them with a never ending string of Career Ending Opportunities (CEO’s) and those who have learned to apply the skills that made them great doctors to lead organizations rather than medical teams. This latter group of physicians apply Business Triage, Customer Triage, Personnel Triage and Marketing Triage to maximize business potential in the same way they used medical triage to maximize patient care.

Physicians entering the entrepreneurial life must however observe several lessons:

• Do not assume your success in medical practice carries any weight in your new market. Be a good entrepreneur, know your market, know your strengths, know your weaknesses and know how to deliver your commitments

• Do not forget the skills that made you a good doctor. The skills that made patients love you and diseases fear you (effective interviewing, rapid decision making, pattern recognition, etc.) all are essential skills for the entrepreneur

• Don’t assume that medical training (residency) is a good model for training anyone or learning to lead. As a survivor of residency training, you are no different from a child abuse survivor and you are prone to abuse those subordinate to you as a result. If you abuse them, you lose them

• Just like a good doctor, good entrepreneurs make referrals, get consults and ask for help these are the keys to success

Physicians, despite the stereotypes, have education and experience that endows them with many of the skills of the greats of the corporate world. The key is to learn to use these skills in the new environment of entrepreneurism.

InstaDecision: 4 Steps to a "Blink" Moment

The past months have seen a resurgence of interest in the ideals of “gut reactions,” intuition and other versions of the insight methods described by Malcolm Gladwell in “Blink!” Business leaders, CEO’s, physicians, disaster field responders, professional speakers and a business consultants use both linear and non-linear decision making (logic & intuition) to create “Blink” moments daily.

Most people know the linear decision making process because t is cultivated by our educational system. It is a system based on the collection of data to support a decision (If A and B then C, but if A and not B then D). Few people realize that we are all born as innately non-linear thinkers.

What Goes Into a “Blink” Moment?

Non-linear process is a four step process consisting of:

1) Pattern Recognition

2) Acknowledging Framing Bias

3) Heuristic Introspection

4) Empathy

Pattern Recognition

Pattern recognition is seeing the patterns and processes behind everything you do and have done. Remember that those with the greatest potential are those who are the most adaptable to any circumstance. They innately understand the process that underlies any other person’s success and can replicate it with ease.

Acknowledge Framing Bias

Think about what happens before a manager goes into a meeting. Rarely will people walk into the situation “cold.” They are briefed on who they’re going to meet and what they’re supposed to accomplish. They draw certain preconceptions, which is called a framing bias.

As long as you know what your framing bias is upfront, then you can allow the situation to develop organically. You can then take away your feelings and your impressions and use them as an analytical tool. That’s the essence of heuristics—taking your feelings and impressions and using them analytically.

Before you can fully immerse yourself in another’s viewpoint, you need to shed your framing bias. First, identify what your preconceptions are about the situation. Second, once you’ve identified them, clear your mind and explore the experience for the first time. What’s your first impression? Are you reacting the way you are because of your preconceived ideas or because you are looking at the situation through fresh eyes?

Heuristic Introspection

Heuristic introspection is a non-linear thought process in which you must “be your customer”. Much like how a fine artist “knows” if a painting or musical composition “works” by going with their “gut,” your employees should “know” what a customer wants.

When you think heuristically, you truly understand the customers’ wants and needs. The next time you want to know how your customers would feel about a particular product or service, adapt a non-linear (heuristic) research approach and become a part of your study base. Your focus group of one (you) will guide your initial thought process toward reaching your customers.

Empathy

Empathy is quite literally to walk a mile in the shoes of our customers, that is to become one with your customers. Become part of the story, even if you aren’t part of the product story. Generally, people like and dislike the same things. If not, you’d never have to wait in line for your favorite roller coaster at an amusement park. What do you feel? Listen to your gut—chances are your customers’ gut would tell them the same thing. You may not identify with the problem, but you’ll know what you need to do to make it feel “right.”

How can you now translate what you’ve discovered into a reproducible decision?

If you’re developing an ad for jogging shoes, you need to think like a runner—even if you’re not one. Why do people run? What is important to runners? How does running make people feel? After you’ve collected your personal research, you’ll be able to speak in the first person as a runner. Pretend you’re one of those successful fiction authors writing under a pseudonym. Tell your story like you live it. Now your customers will be able to personally connect with you because you’ve become one of them.

Why do people underestimate the power of this?

There are two reasons that nonlinear decision making and inductive reasoning are less valued than linear decision making and deductive reasoning. Both are based on the misperception that nonlinear decision making and inductive reasoning are inherently irreproducible, unverifiable, unpredictable and thus unreliable.

1)     Despite that fact that humans are born as empathic, introspective and unbiased "pattern recognition machines," the vast majority become linear deductive decision makers. Through their educational experiences and the very basis of our scientific society, deductive is valued over inductive and linear over nonlinear.

2)     Once the nonlinear and inductive skills are atrophied, those that undervalue what they can no longer do easily (nonlinear decision making) believe that these skills are unlearnable. Nothing could be further from the truth.

Pattern Recognition is an innate human function that ensures our survival in infancy and aids in our safety in daily living. It is easily taught and augmented.

Acknowledging Framing Bias is not an innate function, but is very learnable and since it does not require the shedding of bias, is also readily implemented.

Heuristic Introspection is partially innate. All humans are born with a degree of introspection especially when dealing with ones own needs. Walking in the shoes of another is not an innate behavior, but understanding our reaction in that situation and using that information is trainable.

Empathy is yet another innate function that ensures our ability to identify and even predict the emotional impact of an event on others. Empathy is a practiced skill and the strength of one's empathy grows as one exercises that empathy.

In short the problem is not that "gut" is unreliable or "sample size of one" (intuition) is too small. The problem is in those who devalue this innate human ability.

"The fault lies not in our stars Horachio, but in ourselves."

-          William Shakespeare