I thought I’d share this with you – to demonstrate how passionate the PX community is, and how they desire to support one another and to put patients first.
Journal of Business Research
The purpose of this article is to (1) explicate micro-to-meso linkages of well-being, (2) provide a theoretical framework to guide research on connecting patient experiences to community well-being, and (3) offer guidelines to policymakers. We develop a conceptual framework establishing connections between micro and meso levels through the expansion of patients’ lived ecosystems. We introduce the concept of patient ecosystem management (PEM), an organizational process that focuses on treating patients differently in terms of assessing, managing, and expanding resources to achieve patient health and well-being goals. This process establishes a foundational perspective that is necessary to connect patients’ ecosystems and to facilitate community well-being. Theoretically, this research creates ties between micro-level interactions and a collective measure (community well-being). Policymakers and healthcare professionals should take a PEM perspective, which will require new roles and behaviors, and leverage technology to expand and overlap patients’ individual service ecosystems (intra-alignment), thus enlarging community well-being (inter-alignment).
Patient experienceCommunity well-beingValue cocreationPatient ecosystem managementTransformative service researchWell-beingService Ecosystem
The purpose of this paper is to explore innovations in customer experience at the intersection of the digital, physical and social realms. It explicitly considers experiences involving new technology-enabled services, such as digital twins and automated social presence (i.e. virtual assistants and service robots).
Future customer experiences are conceptualized within a three-dimensional space – low to high digital density, low to high physical complexity and low to high social presence – yielding eight octants.
The conceptual framework identifies eight “dualities,” or specific challenges connected with integrating digital, physical and social realms that challenge organizations to create superior customer experiences in both business-to-business and business-to-consumer markets. The eight dualities are opposing strategic options that organizations must reconcile when co-creating customer experiences under different conditions.
A review of theory demonstrates that little research has been conducted at the intersection of the digital, physical and social realms. Most studies focus on one realm, with occasional reference to another. This paper suggests an agenda for future research and gives examples of fruitful ways to study connections among the three realms rather than in a single realm.
This paper provides guidance for managers in designing and managing customer experiences that the authors believe will need to be addressed by the year 2050.
This paper discusses important societal issues, such as individual and societal needs for privacy, security and transparency. It sets out potential avenues for service innovation in these areas.
The conceptual framework integrates knowledge about customer experiences in digital, physical and social realms in a new way, with insights for future service research, managers and public policy makers.
Citation: Ruth N. Bolton, Janet R. McColl-Kennedy, Lilliemay Cheung, Andrew Gallan, Chiara Orsingher, Lars Witell, Mohamed Zaki, (2018) “Customer experience challenges: bringing together digital, physical and social realms”, Journal of Service Management, https://doi.org/10.1108/JOSM-04-2018-0113
Words matter. They convey our thoughts, they illuminate our understandings, and they can comfort or not. Many people use the word “consumer” in the context of health care without thinking about its meaning. I urge you to think more deeply and clearly about its meaning before you use it again.
According to Miriam-Webster, a consumer is “one that (sic) consumes, such as: one that (sic) utilizes economic goods. E.g., Many consumers make purchases on the Internet” (https://www.merriam-webster.com/dictionary/consumer). To consume is “(a) to do away with completely; (b) to spend wastefully; (c) to eat or drink especially in great quantity; (d) to waste or burn away” (https://www.merriam-webster.com/dictionary/consumes). A consumer, then, has a pejorative meaning, one who is artificially separated from production or productive activities. Is that what you want to say when you use the term “health care consumer”?
The concepts of consumption and production, as separate and distinct activities, were developed long ago by economists, who attempted to quantify economic activities (Vargo and Lusch 2004). This perspective is no longer useful in explaining the cocreation of value, because it holds the potential to create an antagonistic relationship between providers and patients. Why? Because when one produces something of value, and another “consumes” it, value is defined exclusively by the producer. “We do all this great stuff here at XYZ Hospital, and often the patient just comes in and spoils it.” This is fundamentally wrong, and you instinctively know it.
So what is the proper term? More importantly, what is the proper perspective that can guide you into thinking about this issue in a more appropriate manner? I argue that experiences are coproduced by patients, providers, families, caregivers, and potentially many others. Value is always cocreated between at least two parties, most often among multiple parties (Black and Gallan 2015). Health care organizations cannot create value without patients. At most, they create value propositions that invite patients to engage with their services. Only when patients do so, and only when interactions go well, can value (as health and well-being), be cocreated. That is, patients experience health care in such a way that creates a better state for them (progression toward a goal, improved well-being, improved health, etc.).
Likewise, when a health care interaction goes well, a health care organization can capture value in various forms as well. For instance, it can capture financial value (money), it can capture value as employee fulfillment and satisfaction, and it can capture positive feelings and attributions toward its brand and organization (positive word-of-mouth and loyalty behaviors). All of these are desirable outcomes for health care organizations.
So when is a person a patient? A customer? Something else? My position is that people assume multiple roles in different situations, and thus must be treated accordingly. One health care clinician, who I fail to recall, put it thusly: “When a person is horizontal, they are a patient. When a person is vertical, they are a customer.” This is a bit simplistic, but, like all pithy sayings, has an element that rings true. I am not trying to tell clinicians that my perspective usurps their clinical domain; rather, I am rendering unto them what is theirs. When a person is being evaluated clinically, they are a patient, with all the rights and responsibilities that conveys. However, if clinicians, clinics, organizations want positive evaluations, reduced readmissions, bills paid on time, reduced no-show appointments, etc., they should understand that people have choices, degrees of freedom, and a voice. At that time, it is appropriate to consider a person as a customer. Increasingly, people are exercising these rights through technology. This does not make one a “consumer.” It only shows that a person is a complex individual, who acts in different and interesting ways.
When we are allowed to be labelled as a “consumer,” we are permitting ourselves to be pigeon-holed as one who can only offer economic benefit to an organization. We are more than that. Indeed, we are the very people who the health care system is designed to serve (evaluate the meaning of “service” too). Don’t allow yourself to be defined by this term: likewise, don’t define your patients as such. They are whole people, who act in a variety of roles throughout their health care experiences and their lives.
P.S. I also have an issue with the term “THE patient experience.” The term “the” creates an understanding that there is a singular experience that is perfect. Or that patient experience is an object that is separated from the person who is experiencing it. It objectifies the experience, and artificially separates a patient from the timeline of her life. Instead, I urge you to use the term “patients’ experiences,” because it inserts humanity into the term. It automatically urges us to think about patients as people, and experiences as their own. Think of it this way: “Improving THE patient experience” is much different in meaning from “Improving patients’ experiences.”
Black, Hulda G. and Andrew S. Gallan (2015), “Transformative Service Networks: Cocreated Value as Well-Being,” The Service Industries Journal, 35 (15-16), 826-45.
Vargo, Stephen L. and Robert F. Lusch (2004), “Evolving to a New Dominant Logic for Marketing,” Journal of Marketing, 68 (1), 1-17.
Perfect Ratings with Negative Comments: Learning from Contradictory Patient Survey Responses
Lead Research Article in Patient Experience Journal
This research explores why patients give perfect domain scores yet provide negative comments on surveys. In order to explore this phenomenon, vendor-supplied in-patient survey data from eleven different hospitals of a major U.S. health care system were utilized. The dataset included survey scores and comments from 56,900 patients, collected from January 2015 through October 2016. Of the total number of responses, 30,485 (54%) contained at least one comment. For our analysis, we use a two-step approach: a quantitative analysis on the domain scores augmented by a qualitative text analysis of patients’ comments. To focus the research, we start by building a hospital recommendation model using logistic regression that predicts a patient’s likelihood to recommend the hospital; we use this to further evaluate the top four most predictive domains. In these domains (personal issues, nurses, hospital room, and physicians), a significant percentage of patients who rated their experience with a perfect domain score left a comment categorized as not positive, thus giving rise to stark contrasts between survey scores and comments provided by patients. Within each domain, natural language analysis of patient comments shows that, despite providing perfect survey scores, patients have much to say to health care organizations about their experiences in the hospital. A summary of comments also shows that respondents provide negative comments on issues that are outside the survey domains. Results confirm that harvesting and analyzing comments from these patients is important, because much can be learned from their narratives. Implications for health care professionals and organizations are discussed.
Gallan, Andrew S.; Girju, Marina; and Girju, Roxana (2017) “Perfect ratings with negative comments: Learning from contradictory patient survey responses,” Patient Experience Journal: Vol. 4 : Iss. 3 , Article 6.
Available at: http://pxjournal.org/journal/vol4/iss3/6
Download the article for FREE here: http://pxjournal.org/journal/vol4/iss3/6/
Andrew Gallan, PhD, Assistant Professor of Marketing at the Kellstadt Graduate College of Business at DePaul University, and Senem Guney, PhD, CPXP, Founder and Chief Experience Officer at NarrativeDx discuss the interplay between “Top Box” domain scores and patients’ comments in measuring patient experience.
Dr. Guney shares her expertise in how to bring a mixed-methods approach (qualitative/quantitative analysis) to metrics and measurement in patient experience, and Dr. Gallan shares insights from one of his recent studies on the contradictions between perfect scores in distinct PX domains (such as nurse or doctor communication) and comments related to these distinct domains.
This webinar also involves the implications of such contradictions for working with PX data, specifically to determine the drivers for patients’ willingness to recommend a hospital.
To access video of the webinar, please go here:
This is a guest blog post by Andrew Gallan, PhD, a teacher, researcher, and adviser to organizations on designing services to improve patient experience.
Now that over 50 healthcare organizations regularly publish patient evaluations of physicians on their public-facing websites (Ed Bennett Consulting 2017), transparency around physician ratings and reviews has become a growing focus in healthcare. University of Utah Health Care is a pioneering institution in today’s transparency movement.
While transparency around ratings can (understandably) be stressful for physicians, it can be very useful for patients
searching for the right physician for their own care (Patient Engagement HIT 2017). Transparency is about presenting digestible data to patients to help inform their purchasing decisions.
To that end, survey scores are converted into a five-star system; and all comments, positive and negative, are posted on a hospital’s website with redacted identifying or personal information.
Why are healthcare organizations adopting physician rating transparency?
It is now imperative for health care organizations and professionals to manage their online presence and reputation (PatientTrak2017). While Yelp and other third-party online sources capture attention, physician profiles on providers’ websites typically outrank other sources of information and provide more valid and reliable data (Mahoney 2016). CMS-mandated data, such as those collected from CAHPS surveys, are from verified patients of a specific provider, and the questions have been developed with good psychometric qualities.
When a healthcare organization transitions toward online physician transparency, they motivate physicians to improve performance, explains Vivian Lee, M.B.A., M.D., Ph.D. in a recent article for the New England Journal of Medicine. When physicians are compared to one another, very often they seek out counsel to improve the service they provide to patients. This can lead to improved patient-centered care and quality outcomes.
Then, the question for physicians and healthcare leaders becomes: If I’m being held accountable to certain standards, how can I improve my scores?
The answer to this question lies in patients’ comments. Patients might give high survey scores to physicians, but they describe their true care experiences in their comments. Physicians can learn from these first-person accounts about what patients need and expect of their care. It’s also true that people identify with stories over numbers, so a sample of patient comments that represent a specific trend out of aggregate qualitative data would resonate very well with physicians about the improvements they need to make.
How can healthcare organizations manage what is now transparent to potential patients?
As a result of physician transparency, it is more important now than ever to bring a scientific approach to understanding what patients are saying in their own words. Healthcare organizations need to make sense of both structured data (survey scores) and unstructured data (patient comments). By analyzing patient comments, providers can learn about patients’ experiences above and beyond CAHPS domains. Artificial Intelligence (AI) and Natural Language Processing (NLP) are methodologies that provide the capability to analyze and make sense of large amounts of text. When this analytical capability is coupled with intuitive visualizations on dashboards and easy-to-digest reports, such as those offered by NarrativeDx, it becomes so much easier for providers to learn from and build improvement actions on what patients are saying.
The goal of patient experience improvement is to gain a better understanding of what is important to patients.
Some examples that bring this issue to life include:
- If patients complain about food, what are they saying? Are they commenting about taste, temperature, choice, or other issues?
- If patients complain about noise, what are they hearing? Alarms, conversations, other patients, visitors?
- If patients don’t understand discharge information, what do they recall? Do they remember the timing of when the information was given, the amount of information provided, instructions surrounding new medications, follow-up appointments, or other issues?
Patient experience professionals can now engage new techniques and tools to unearth additional insights from existing data that will help improve care experiences, and happy patients and families will in turn give much higher ratings to physicians.
Andrew Gallan, PhD specializes in researching, teaching, and advising organizations on designing and delivering patient-centered care. He has worked with organizations including Mayo Clinic (AZ), University of Chicago Medical Center, UPMC, and Advocate Health Care on their journey toward delivering world-class care. Andrew has engaged audiences as a keynote speaker, breakout presenter, and committee facilitator and advisor. His graduate class on Patient Experience, the first in the nation, is among the most highly rated classes at DePaul. He is a Beryl Institute speaker.
When home health providers think of the “patient experience,” high-quality care is likely what comes to mind first. In reality, physical care may just be one aspect of an outstanding patient experience.
The real definition of patient experience can be beyond what providers and caregivers are used to, Joyce Boin, principal consultant at Strategic Health Care Solutions, explained to Home Health Care News.
“All patients assume as a home health provider you are sending a competent caregiver. The ‘wow factor’ comes in when you expand that idea even further than just great care,” Boin said. “The above and beyond comes from compassion and empathy.”
Patient Experience Project
In addition to caregivers showing compassion and empathy, another way home health providers should train caregivers to go above and beyond is by teaching how to engage patients in the care process, Andrew Gallan, an assistant professor at DePaul University who researches the patient experience, told HHCN.
This engagement could be as simple as asking the patient one or two extra questions to learn more about them, or explaining certain aspects of the patient’s recovery to keep them engaged in what’s happening.
Gallan has made the patient experience in health care his focus. He began his research in hospitals, but moved into the home care sector through a project with an Illinois home health provider, Advocate at Home, where he and Boin partnered together.
The project consisted of three phases that took just over two years. First, a survey was conducted among home health patients to see where caregivers stood in terms of quality of care. Then Gallan pinpointed the top drivers of the patient experience and created an index to track for those things. The items he tracked included communication with home health staff members, taking care of emotional needs and overall perception.
Second, Gallan did phone interviews with the patients to try to find out more details about the areas in phase one. In phase three, Gallan attended ride-alongs with home health staff to witness the caregiver/patient relationship firsthand. In total, Gallan made about 40 patient visits in the city of Chicago, the suburbs and rural areas of Illinois.
The results of the project found that patients overall had very good relationships with their home health providers, but they were reluctant to talk about their emotional state.
“Home health providers did a very good job of delivering the actual care, but the relationships formed could have been better,” Gallan explained. “The caregivers could have been better active listeners. Something as small as putting away computers or tablets and taking a few extra minutes to ask a few more questions could help create a clearer picture of the patients’ emotional state.”
Making goals very clear can also improve the overall patient experience, added Gallan.
“If patients can identify a goal, they can see a light at the end of the tunnel,” he said. “It’s a highly motivating thing. If caregivers can help them identify those goals, patients can make significant progress.”
Though the project is over now, Gallan continues to work with Advocate at Home to help implement the full patient experience and build upon the project’s findings.
Investing the Upfront Time
Caregivers can improve the patient experience is to work on building a strong relationship with the caregiver by encouraging patients to become engaged. Allowing caregivers to spend more time on visits sounds like it could be inefficient, but investing time upfront to build relationships and develop goals with patients actually has a positive impact on recovery times, according to Gallan.
“I know some of the pushback about being more engaging with patients is because it will take more time, but my response is that if it’s done well, it’s not going to be that much more time down the road,” he said. “And then, if the patient knows what’s expected of them from the beginning, once the nurse comes in they don’t have to reinvent the wheel.”
Building a strong relationship between caregiver and patient can also help put family members at ease.
“It’s a cause of concern and anxiety for some families when their loved ones are receiving in-home care,” said Boin. “The idea of having caregivers as somewhat of a support system is what value-based purchasing is really going to buy. If caregivers can deliver on that, the patients and caregivers will become more efficient.”
Written by Alana Stramowski
Two years ago my 89-year-old father had minor surgery on his leg to remove a cancerous growth. The dermatologist had to scrape so many layers before eliminating diseased tissue that he recommended my father visit the wound care center to speed healing. In this organization, wound care was part of the Physical Therapy department on the lower level. My father and I made our way down, and scheduled two appointments per week, Tuesday and Friday, for what would be a total of six weeks. Then we transitioned to only once per week as the wound healed.
My father would wait only a minute or two before being called back. Richard and Mark took turns applying topical anesthetic, debriding the wound, and wrapping up gradually diminishing wounds on my father’s leg. This took about 15 or 20 minutes, and I’d bide my time in the waiting room.
It didn’t take long for me to recognize the regulars. Despite my best efforts to pass the time checking e-mails, the stock market, and my never-ending Scrabble matches, I couldn’t help but to glance around whenever there was action in the reception area or waiting room. I made mental notes of the patients I saw most often.
The young college-aged soccer player on crutches and her equally blonde mother who have permanent grins as if to convey the temporary nature of their predicament.
The knitter who waits with unwavering patience for her appointment time, only to abandon her knitting most willingly once she hears her name.
The burly older Polish man with the thick accent who brings plastic bags and the newspaper every time he visits. He sorts through the paper, separating the wanted from the unwanted, throwing away or sometimes leaving behind the inserts, ads, and undesirable sections. The staff knew to circle back after he left to check for trash.
The elderly gentleman with the walker, who without exception goes to the men’s room just before his therapist comes to call for him. And his wife who always rolls her eyes to the therapist, which is enough said.
The older couple who graduated from the university at which I teach, who one time engaged me in discussion about my affiliation based on my logoed sweatshirt. Since then, they haven’t even met my glance; perhaps time has diminished their recognition of me, particularly since I haven’t worn identifying clothing since then.
I’ve also observed the staff, both the ones who are affiliated with the department and those who pass through. I began to notice an almost metronomic tendency for actions to repeat themselves. The employees, who walk and talk through the waiting area as if there was no silence; who wait for the elevator as if no one will get off when the doors open; who whisk past and stare at the floor while listening to music through ear buds; who call everyone who checks in or out “sweetie” or “honey”; who listen to various iterations of almost scripted check-out conversation (“be gentle with the bill, I’m sore…”) and then feign interest and laughter. Initially annoying, it became familiarly amusing after a while.
Physical therapy and radiology share a common check-in desk, long enough to spread from one patient entry to the other. There are always more PT patients than radiology patients, so PT knows to check for their patients in waiting room chairs on both sides. And radiology knows not to question anyone wandering over to their circle of chairs that doesn’t look over. The PT patients are recognized and instantly checked in upon emerging from the elevator. On the other hand, for every eight or so PT patients, there is one radiology patient who pops out of the elevator, pauses to read the signs, and then nervously walks over to the receptionist.
Most of these patients are one-and-done; a simply x-ray or sonogram to eliminate something from the list of potential diagnoses. On a rare occasion there is a patient who walks in emitting stress and angst to suggest that she is in the midst of a life-changing event. The mother who pushes a stroller with a baby who wears a mask; the middle-aged woman who checks in for an MRI of her chest; the elderly woman and her daughter who are silent except for the simple word or two of direction from the daughter. These are the cases I noticed the most, for they are a brief glimpse into the potentially horrible world that is theirs alone to inhabit.
After all the trips, and time spent, and weather tolerated, I’m glad my father’s leg has healed. I’m also grateful that I don’t have to make the time to pick him up from his apartment at his independent living facility and drive him to and from the clinic. However, I’ll miss seeing him so frequently, even though I see him at least once a week. Surprisingly, I’ll also miss the observation, the regulars, (some of) the staff, and the routine. It seems that the wound care clinic transformed from a treatment facility to a Cheers-like venue where I expected the next man out of the elevator to be greeted with a chorus of “Norm!”.
Learning #4: Understanding the patient experience requires a strategic plan, the proper tools, and humility.
Frameworks and tools exist to help organizations better understand their processes from the patient’s perspective, designed to help organizations strategize around improvement, innovation, and redesign to enhance quality, safety, and productivity.
Implications: Understanding what your patients experience when they are in your facility requires humility. This may not be what you think it is; a recent article outlines major components of humility: “Recognition of what she owes to others, comparison with a reality that is greater than her, and finding something that has a high objective value that leads her to acknowledge her smallness.”1 It is a positive virtue that motivates an individual to be open to others, to listen carefully to others, and to assume an attitude of looking for guidance.
It is from this perspective that a leader creates a humble organization; one that has a desire to understand what patients and families go through to obtain care from and with your organization. Thus, putting yourself into the shoes of another, through Shadowing, is an important tool to understand care from the patient and family perspective. Shadowing is a cultural change agent, an orientation tool, and a reminder of your organization’s mission. What you see will go beyond your pre-conceived notions of what it is like to be a patient. It will connect you to other human beings, their vulnerability and goals, and bring out your sense of empathy.
Once you have Shadowed patients, it is imperative to map the process using care experience flow maps, service blueprinting, or other tools to create a clear image of what is. Comparing what you have designed to what customers expect using the Gap Model of Service Quality will help you to reimagine what could and should be, and to redesign the process to best accommodate the patient. By using this methodology your department will also most likely save costs and improve safety.
Making a commitment to seeing your organization’s processes from your patients’ perspectives is not easy – it requires a high level of dedication from top leadership. A Servant Leadership model applies as well, where leaders put the needs of others before their own needs. After all, as humility research reminds us, “the humble leader is precisely the person who is best qualified to transform his firm into a profitable, successful, and respected organization.”
1 Argandona, Antonio (2015), “Humility in Management,” Journal of Business Ethics, 132 (1), 63-71.