Mickey Mouse Patient Satisfaction

November 8, 2009, 6:30 a.m.

UIHC's Troubles: Is Orlando the Answer?
(brought to you by FromDC2Iowa.blogspot.com*)
That the UIHC administrators want a trip to Orlando, Florida's Disney World raises a number of issues: (1) the public relations, and legislative, backlash, (2) whether the UIHC needs improved "patient satisfaction," and if so (3) the appropriateness of, and alternatives to, the Disney program, and finally (4) emerging concerns about the judgment of UIHC management generally.

But first, here are links to entries on some of the other hot topics from the past week or so that are now getting the most direct hits, among which may be the entries you are looking for:

The UIHC's controversial "contributions from patients" proposal. "UIHC: 'Sick Brother, Can You Spare a Dime?'; A Check-In and a Check," October 31, 2009, 7:00 a.m. (with links to additional, related material -- and now with over 30 of the Press-Citizen readers' comments on B.A. Morelli's stories).

School boundaries, school boards, and the ICCSD. "School Board Election: Now Work Begins; It's Swisher, Dorau, Cooper; Old Board 'Starting Off Backing Up' With Consultant and Tough Decisions," September 9, 2009, 7:00 a.m. (with links to 11 prior, and related, blog entries).

Board of Regents and State universities' budget cutting. "Cutting Slack, Cutting Budgets; Regents, University Presidents, Deserve Some Thanks and Credit," October 30, 2009, 8:30 a.m. (with links to prior, related blog entries).

Spence break-in grand jury proceedings. "UI Spence Break-In: Gazette Scoop Illustrates Issues," October 27, 2009.

A week ago last Saturday the Press-Citizen cleverly ridiculed into reality the School Board's "governance by clicker." Editorial, "Board Needs Civil Dialogue Not Clickers," Iowa City Press-Citizen, October 31, 2009. Yesterday they did an equally creative job on the UIHC's latest Mickey Mouse proposal: a $130,000 edu-tainment trip to Disney World for some of the institution's top administrators. Editorial, "Time to cancel UIHC's trip to Disney Institute," Iowa City Press-Citizen, November 7, 2009:

When Republican state legislators began complaining Thursday about the University of Iowa Hospitals and Clinics' plan to spend $130,000 to send hospital officials for a training session at Walt Disney World Resort, the only response from UI officials should have been: "You're right. That doesn't pass the common sense test. At a time when the state is slashing budgets and the hospital is facing budget cuts, this absolutely is the wrong time to implement this program."

Instead, UI officials actually have been trying to defend the decision as a necessary "small investment" that will reap big rewards in improving the hospital's low scores in patient satisfaction. In an e-mail sent throughout the UI community, the top hospital brass tried to spin the $130,000 as a good deal for the hospital. . . .

To make the case for why UIHC needs to be Disneyfied, the e-mail linked to three PR testimonials on how the Disney Institute has "partnered" with other hospitals on their "journey to excellence."

[Here's one example from the three the Press-Citizen quoted:]

• Back in 2001, the Arkansas Children's Hospital was struggling with the recruitment of critical staff, and its series of short-term fixes weren't correcting the problem. After the hospital took its senior management team for the Disney Institute's "Excellence in Healthcare Leadership" program -- which included visiting Disney sites and spending a short time as Disney "Cast Members" -- the management team was able to brainstorm ways to improve their retention efforts. (www.disneyinstitute.com/About_Us/PDFs/DI_CaseStudy_ArkansasChildrenHospital.pdf). . . .

But this isn't the 1990s . . . [or] even the start of the 21st century. This is the end of the first decade of the 21st century, when people are losing jobs left and right, and the so-called "small investment" of $130,000 represents nearly three times the annual salary of the average Iowa family.

We're all for UIHC changing its culture to improve patient care. But right now we can see only one benefit to UIHC officials visiting the happiest place while on Iowa is on budget-slashing roller-coaster ride: It will help bring together two normally at-odds groups, union leaders and Republican legislators, as they find common ground in how understandably appalled they are over this decision.

The paper earlier explained, "UI is planning a trip for 35 senior UI Health Care and UI Hospitals and Clinics administrators, doctors, nurses and other personnel . . . said Gordon Williams, UI Health Care chief of operations. The trip would include plane, hotel, meals, two and a half days' training and 'the Disney experience,'" he said. Williams and UI spokesman Tom Moore defended the plans on Thursday [Nov. 5] . . . “We haven’t though about putting it on hold because this initiative is so important,” Williams said. Moore said this plan has the support of UI President Sally Mason . . .." B.A. Morelli, "UI Officials Consider Disney Trip," Iowa City Press-Citizen, November 5, 2009. And see, B.A. Morelli, "Politician questions UI Orlando trip; Officials say Disney Institute the best around," Iowa City Press-Citizen, November 6, 2009, p. A1; B.A. Morelli, "2 lawmakers slam plans for U of I Disney trip," Des Moines Register, November 7, 2009; Diane Heldt, "UI trip to Florida decried as wasteful; Lawmaker may push for more oversight of state regents," The Gazette, November 6, 2009, p. A1 (characterized as "part of an 'epidemic of arrogance' in the state regents system. Jeff Kaufmann, R-Wilton, said Thursday that the trip to Orlando, Fla., at an estimated cost of $130,000, is the latest in a string of poor fiscal decisions"); Sam Lane, "Legislators upset over UIHC’s trip to Disney World," The Daily Iowan, November 6, 2009.

There are a number of issues here, summarized in the opening of this blog entry: "(1) the public relations, and legislative, backlash, (2) whether the UIHC needs improved 'patient satisfaction,' and if so (3) the appropriateness of, and alternatives to, the Disney program, and finally (4) emerging concerns about the judgment of UIHC management generally."

1. Public Relations. What will be the reaction of the public, media and Iowa Legislature to what many Iowans will understandably perceive as an all-expense-paid "vacation trip" for hospital administrators earning multiples of the average Iowa family income? It should have been easily predictable. Was that thought about at all by top UI and UIHC administrators? (As I noted in a comment about a DI editorial questioning the patient donation proposal, "Like the boy in The Emperor's New Clothes, our students can spot nakedness of which their adult administrators are either too blind or too frightened to speak." Editorial, "UIHC donation plan would inappropriately pressure patients," The Daily Iowan, November 5, 2009.)

Even if at another time and place it would have been a wise use of $130,000, as its defenders insist it is now (a matter I would dispute), it should have been obvious that this was not the time. Iowans in general, and UI personnel in particular, are facing unemployment, mortgage foreclosures, and bankruptcy. Orlando is the farthest thing from their grasp. See the Nov. 10 story, B.A. Morelli, "Union head slams UIHC Disney trip; Officials: Trip essential to improving customer service," Iowa City Press-Citizen, November 10, 2009 ("'It is completely unacceptable at this time, when state workers are facing layoffs and Iowans are looking at major cuts to services, for the UIHC to plan a trip to the Disney Institute in Orlando, Florida," AFSCME President Danny Homan said in a statement Monday. The decision 'shows the tone-deafness of the UI to the current situation the rest of state government is facing.'").

Iowa legislators' criticism of this trip necessarily reminds one that, "Lawmakers in Washington . . . criticized the $442,000 that an A.I.G. subsidiary spent on a weeklong resort retreat for top sales staff, within days of receiving government aid." Jonathan D. Glater and Vikas Bajaj, "Cuomo Seeks Recovery of Bonuses at A.I.G.," New York Times, October 16, 2008, p. B1.

The Gazette adds more examples of public relations insensitivity by the privileged: "H1N1 vaccine was shipped to big Wall Street companies while public clinics . . . don’t have enough" and amidst "employee layoffs . . . Linn County supervisors . . . allow . . . pay increases . . . for about 140 management workers." "Gomers," The Gazette, November 9, 2009, p. A4.

But never mind that the UIHC isn't the only institution with public relations gaffs. Never mind that for UIHC a $130,000 expense is but a drop from its $1.4 billion gross revenues bucket (1/100th of 1%; see source, below). Never mind that an argument can be made the money isn't coming from taxes. Never mind that the idea's promoters argue it's the least-cost way to get some improvement in patient satisfaction (as A.I.G. executives undoubtedly argued the benefits in increased sales that would result from the resort retreat).

It's a public relations disaster, especially coming on the heels of last week's revelation of plans to ask new patients for financial contributions just as they are checking in at the hospital [see "UIHC: 'Sick Brother, Can You Spare a Dime?'; A Check-In and a Check," October 31, 2009]. You want to improve "patient satisfaction"? You might start by not asking patients for donations at the very moment they are most vulnerable, and already concerned about how they are going to pay for the procedures they are about to receive.

Making predictions about the public's reaction, fashioning public relations and "strategic communications" programs, requires some capacity for empathy with the public. When you're traveling on a Gulfstream it's hard to imagine what it's like for those who can't afford to travel on a Greyhound (or what their trip is like when they can afford it). When you're paying $40,000 for your kid's college tuition it's hard to relate to those who are trying to support a family of four on $20,000 and who can't even dream of paying Iowa's tuition for their kids. When you think nothing of the cost of a meal at Iowa City's most expensive restaurants . . . ah, but hopefully you get my point (whether or not there is any UI administrator who has ever traveled on a Gulfstream or Greyhound, sent kids to $40,000 schools, or actually likes the food at those restaurants).

One gets the sense that there is a bit of a disconnect between those who are making these decisions, the worlds in which they live (both literally and figuratively), and the Iowans -- including many of the UIHC's employees as well -- who are reacting to them.

2. Patient Satisfaction. Given virtually all administrators' inclination to put the best light on institutional deficiencies, if UIHC executives are willing to acknowledge they have a "patient satisfaction" problem you can bet they probably do.

I have some affection for the UI Hospital. My younger sister and I were born there, I worked the cash register and serving line at its employees' cafeteria while in high school, have occasionally volunteered as a guinea pig for a clinical trial, and have returned many times over the intervening years as a patient. John Colloton's accomplishments during his leadership in building what the UIHC is today invoke awe. Many of the institution's doctors and departments are not simply "among the best" they are actually ranked number one in the nation. I certainly admire Gordon Williams' accomplishments as a hospital administrator at many institutions before we were lucky enough to get him here. And I must say, I thought UI Vice President for Medical Affairs Jean Robillard's remarks at the "Healthcare Reform: A Civil Discourse" forum last month were among the most informed, articulate, candid, compasionate and public spirited I've heard from anyone inside the health care industry during this past year [see, Kevin Hoffman, Locals Address Health Care," The Daily Iowan, October 20, 2009].

I've had my own frustrating experiences with the hospital and heard the stories of friends over the years: lengthy waits well beyond the time of appointments, inaccuracies in billings, lost records and x-rays, a seeming lack of effective communication between departments, or a general sense of feeling lost in a vast, impersonal system. But this blog entry is motivated by neither personal anecdote nor animus. I simply take as a given, based on the UIHC administrators' representations, and press representations that the Disney World visit is supported by the UI President Sally Mason, that patient satisfaction at the UIHC is not just a collection of anecdotes but is a serious and systemic problem.

3. Disney Appropriateness and Alternatives. I have no personal experience with the Disney program, and am even willing to accept its advocates' representations that it is the best at what it does. I just question whether what it does is what the UIHC needs, or that even if it were, a day or two of exposure to Disney's wisdom and the Florida sun will cure what ails the UIHC.

Patient satisfaction is neither rocket, nor medical, science.

(a) The Walmart Standard. As a school board member visiting schools, I expressed concern to the superintendent at the number of times I would walk into a reception area, stand in front of a person behind a desk, and not be greeted by anyone, let alone with a smile. I suggested we hold our employees (some with PhDs and masters' degrees) to what I called "the Walmart standard." It was not intended to disparage either Walmart or the ICCSD, but to dramatically make the point. You may have had the experience: An employee is sitting on the floor, organizing stock. You ask where something is located. They look at you, smile, stop what they are doing, get up, and if necessary walk to the northwest quarter of the 40-acre store, with some friendly chat along the way, and then point to the spot on the shelf where what you're looking for is located. I figured if Walmart could train high school graduates and dropouts to that standard, we ought to be able to do as well with our school district employees. See, e.g., Nicholas Johnson, "Complaints Help Solve Problems," Iowa City Press-Citizen, August 17, 1999, p. 13A.

(b) Hire for Attitude. “'We hire for attitude and train for skills,' says Dean Worker, recruiter for Southwest Airlines. At Southwest Airlines . . . maintaining the corporate culture is dependent upon the loyalty and devotion of its employees . . .. The key to fitting in . . . is not just how well you do the job, but how good your attitude is while you do it. As a result . . . Fortune has consistently ranked Southwest Airlines among the top five of Best Companies to Work for in America, and according to the April 2003 issue . . . Southwest is an employer of choice among college students." "Secrets from the Other Side: Working for Southwest Airlines," St. Louis University Career Chronicles, October 2003.

Almost everyone has some skill or talent that enables them to be as good or better than anyone at doing a specific task. Greeting, or working with, the public -- especially those members of the public suffering the anxiety or stress of some hospital patients -- is not a talent possessed by all. That doesn't mean those who neither enjoy nor do such work well are bad people, or that they wouldn't be well qualified for other tasks. It just means that institutions would be well advised, in filling positions that involve working with the public, to "hire for attitude and train for skills" -- rather than hoping that a trip to Disney World can turn around an attitude that has had decades to develop.

(c) Employee satisfaction. Job One for any administrator concerned about patient (or customer) satisfaction has to be employee satisfaction. Employees who are over-worked, under-paid and under-appreciated, who are scarcely noticed let alone thanked and praised, are not going to be at their best in creating patient satisfaction. And for administrators to merely follow the instruction to "be sincere, even if you don't mean it," isn't enough; employees can tell the difference. As an "Anonymous" put his or her example about life in Jessup (a comment on an earlier blog entry): "Every day, when they [President David Skorton and Provost Mike Hogan] came in they would stop and visit for a minute with each person in the offices around them. They'd ask about our families and our day." Nicholas Johnson, "A University's Strategic Communication; A Modest Proposal to the Regents' University Presidents," October 7, 2009, comment 10/09/2009 07:05:00 PM.

(d) The Fundamentals. A hospital is not a big box store or used car lot. Willy Loman's "shoeshine and a smile" (that is, just basic friendliness and attentiveness) can be a great place to start in improving patient satisfaction. But a hospital needs, among other things, smooth working integrated systems. Mayo Clinic (which I have never visited as a patient) seems to have such systems, based on what I've heard from those who have been there. Rather than taking 35 people to Disney World the UIHC might consider sending one person to Rochester, Minnesota, to: (1) observe their procedures, (2) take notes, (3) come back to Iowa City, and (4) do what they do. It is my impression, for example, that there is little or no waiting; clinics are not routinely overbooked. There are friendly greetings. Patients are not repeatedly required to fill out forms asking for the same information. Records arrive at each destination before the patient. Personnel are familiar with their contents, know why you're there, and where you're going next. Oh, and the first thing patients hear is not an appeal for financial contributions (talk about "patient satisfaction")!

I understand that UIHC is not Mayo. It must treat patients who could not afford or get into the Mayo Clinic. UIHC is a teaching hospital; training new doctors requires they be able to see patients. OK, so UIHC can't emulate everything Mayo does; it can at least copy what it can do.

The controversy surrounding this proposed Disney World trip has produced dozens of comments on newspapers' online editions from readers -- virtually all expressing something between outrage and ridicule. But I noticed three this morning (Nov. 10) that I thought consistent with and reinforcing of the points I'm making here, constructive, helpful and worth including in this blog entry. Coming as they do from people I do not know and have not talked to, they drive home the point that Iowans' values are widely shared: "patient satisfaction" is not rocket science, it's just common sense. They are attached to B.A. Morelli, "Union Head Slams UIHC Disney Trip; Officials: Trip Essential to Improving Customer Service," Iowa City Press-Citizen, November 10, 2009:

"[E]ven I won't go to UIHC for care unless I need something really specialized, because I don't have a whole day to devote to a clinic appt that should take an hour--and I work there." Gilgamesh37, 11/10/2009 6:26:08 AM

"All UIHC needs to start doing is keeping the appointments THEY schedule with their patients. That would solve over 50% of their patients complaints." iowahawkeye, 11/10/2009 6:25:44 AM

And, for a testimonial that the "Mayo treatment" is widely available and easily achieved:

"[A]t at Mercy Hospital in Iowa City, I was immensely impressed with the sensitive, fast and personable good service I received in several departments. Persons at all serice levels seened dedicated to my comfort, my understanding of the procedures . . .. As I left last week they handed me a 1-page satisfaction survey with the request that I fill it out only if I wanted to. I did.These people haven't even had a free paid trip to Disneyland to my knowledge and still they did a great job -- just being courteous, professional and just plain nice." Harvey, 11/10/2009 6:24:17 AM

What a dramatic distinction there is between being handed a request for donations when you check in, and being handed a satisfaction survey when you check out! That pretty much sums it up.

(4) Management Judgment. The Disney World trip is UIHC's second public relations disaster in the last two weeks. The first was the proposal to cover financial shortfalls with appeals to patients for donations -- above and beyond the medical bills; see "UIHC: 'Sick Brother, Can You Spare a Dime?'; A Check-In and a Check," October 31, 2009. This was problematical for at least three reasons: the proposal's substance (asking patients for donations at all, and worst of all when they're at their most vulnerable), responding to an avalanche of outrage and ridicule with a defensive effort to justify it, and in doing so to misrepresent the extent to which it was being done by other hospitals. As The Gazette reported on October 31, "[UIHC spokesperson] Moore said the idea was based on programs at other hospitals. Three of those he cited, however — the University of Michigan, University of Pennsylvania and Mayo Clinic — said they had no such system in place. . . ." Of course other hospitals receive contributions from people who happen to have been patients in the past -- as a part of their general donor base -- as does the UI Foundation. That's not, and never was, the issue -- nor can it be the justification for fund raising efforts to be the first thing patients confront when they arrive at a clinic. The issue involves soliciting patients -- especially when they are checking into a clinic. As I wrote in a comment on a Daily Iowan editorial, "To tell reporters (as they did) that others do this, when they don't, is either sloppy investigation of details, insensitivity to ethical nuance, or (hopefully not) deliberate disingenuousness."

Either the patient donations proposal or the Disney World trip, taken alone, causes one pause. Taken together they prompt one to ask, "What else is being proposed by the folks who brought us those two great ideas, somewhere within that labyrinth of offices and hallways that is the UIHC, that we don't yet know about?"

For example, on October 19 I wrote:

Here we are, confronting a budget crisis. The Board of Regents has put a freeze on hiring, voted for a halt to construction (until they voted against it), is considering a mid-year tuition increase, layoffs, cuts in salaries and benefits, has at least nodded in the direction of fairness in all of this, and what does the UIHC do?

Morelli reports that it, "filled a newly created position of chief medical information officer last week -- the same day university officials were instructed to consider temporary and permanent layoffs and a tuition surcharge" (an emphasis in the Register's story and headline that doesn't appear in the Press-Citizen's version).

And why is this position necessary? Because it accompanies a $61 million investment in a new computer system -- an amount that exceeds the cuts being asked of all the Regents' institutions combined.

After reciting the UI's creation of four senior administrative positions and three new vice presidents, Iowa Representative Jeff Kaufmann, R-Wilton, expressed the same kind of concern about the "chief medical information officer" position as other legislators expressed about the patient donations and the Disney World trip: "I can't believe they've gone this long and they are adding it into a half-time position -- and that couldn't wait? Even if it is $45,000, I don't care if it is $5,000, it sends a message to people at the bottom of the organization. I just don't understand it right now."

A comment put up on that blog entry of mine, by "Anonymous," reads as follows:

UIHC administration decided to spend 60 million (probably more) to install a new buggy pathetic software system. It takes 18 clicks to write a prescription, which is often wrong.

The system -- EPIC -- was abandoned in a Calif hospital when after $160 million, the system determined it would take ONE BILLION $$ to make it work.

This system has been determined to increase morbidity and mortality, while adding huge costs.

Any other story is denial...and it is criminal that leadership and the press do not tell the honest truth on this one.

Obviously, I can't possibly know if these assertions are true, and I don't represent that they are. But what seem (to me) really serious errors of judgment over the past two weeks make it seem more worthwhile for some reporter to track this story down. And see the blog entry on which this comment appeared, Nicholas Johnson, "UI Budget: Waivers Waive Goodbye to Savings," October 19, 2009.

If I'm reading the auditors' report correctly, in 2006 (the latest report I could quickly find) the UIHC controled over $1 billion in assets (p. 9), had gross patient charges of $1.4 billion (p. 26), and investments (as in stocks and bonds) of nearly half of $1 billion (p. 16). KPMG Independent Auditors' Report, UIHC Financial Statements, June 30, 2006 and 2005.

When you compare numbers like that with, say, the UI's appropriation for the teaching of German (a program now abolished entirely, I believe) it makes the cuts being asked of the UIHC look pretty small -- though I doubt they look that way to those taking cuts in pay -- and the costs of the Orlando trip not even the equivalent of that for executives' coffee. B.A. Morelli, "UIHC must cut $17M from budget," Iowa City Press-Citizen, November 5, 2009.

But that fact only makes more troublesome, not less, the $60 million acquisition, the new positions, the Disney World trip (and the proposal to exact donations from patients).

The Iowa Legislature, and the people of this state, simply must have confidence in the quality, common sense, and ethics, of those responsible for the decisions affecting this multi-billion-dollar medical operation for which all Iowans are rightfully appreciative and proud.
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* Why do I put this blog ID at the top of the entry, when you know full well what blog you're reading? Because there are a number of Internet sites that, for whatever reason, simply take the blog entries of others and reproduce them as their own without crediting the source. I don't mind the flattering attention, but would appreciate acknowledgment as the source, even if I have to embed it myself. -- Nicholas Johnson
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