Combining expertise, experience, and data from millions of people – patients and consumers along with healthcare employees and executives – the team at NRC Health’s Human Understanding Institute forged a distinct perspective for the year ahead. The Human Understanding Institute produces resources like this Experience Perspective and monthly nSights to help NRC Health customers turn aspiration into action by prioritizing what matters to patients, families, communities, and care teams in the real world.

Human Understanding^® is the line of continuity running through all of NRC Health’s work, including this Experience Perspective. Section 1 offers our viewpoint on a set of focus areas that health systems can embrace on the path to realizing the New Awesome. Section 2 shares important trends that we’ve tracked to provide context for the work ahead.

Healthcare’s Headwinds

The challenges facing healthcare are familiar when examined individually: decreasing margins, clinician and care-team burnout, staffing struggles, and deferred care, to name a few. Over the past few years, COVID-19 generated a perfect storm as these headwinds coalesced into a collective force. These challenges have been replaced by more existential questions, like how to keep the lights on. Mike Slubowski, CEO of Trinity Health, plainly conveyed the effects of this tumult on health systems:

Consumerism’s comeback

Despite the unprecedented pressure on healthcare organizations, consumers and patients continue to expect a great experience. People have grown accustomed to having everything come to them – a stream of easy, frictionless, right-to-my-door experiences has become the norm for many. As consumers return to healthcare, most are unwilling to accept the pre-pandemic status quo. Instead, they are looking for smooth access to care on the front end, meaningful encounters, and plenty of value on the back end. Every moment of interaction with a health organization – whether through its website, a clinical encounter, a bill, or marketing outreach – defines both the overall experience as well as the organization’s reputation or brand. The stakes of consumerism in healthcare have never been higher. Meeting them requires a fresh approach.

The New Awesome

What do successful organizations do when expectations and stakes are high? Deliver. Dr. Gregory Makoul, NRC Health’s Chief Transformation Officer, first invoked the New Awesome at the 2021 NGPX Conference when he asked a panel of experience leaders to think beyond the New Normal. We have facilitated several leadership discussions on this topic and always come away impressed by the extent to which leaders rally around the idea of the New Awesome while being mindful of everyday realities. While the idea of getting back to ‘normal’ might be comforting given the perfect storm facing healthcare, we all know that we can do better.

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Nobody wants to be treated like a datapoint, a number, a case, a segment, or an aggregate. Providing excellent care requires a deep understanding of individual circumstances, needs, and expectations. That’s why we are leading the charge toward Human Understanding – understanding and addressing what matters most to each patient as a unique person and remembering that every person’s experience extends well beyond the healthcare setting.

Meetings between experts

One productive way to make Human Understanding more tangible and prevalent is to remember that care teams are experts on clinical care, patients are experts on their lives, and care works best if these experts share their expertise. When this happens – when patients are treated as unique people – we see major gains in loyalty and likelihood-to-recommend, both of which bode well for quality of care, health outcomes, and future revenue.

How do we know? Our August 2022 nSight on Patient Perceptions of Human Understanding introduced the Human Understanding Metric (HU^me), a straightforward measure of Human Understanding that is person-centered, equity-focused, and valid across care settings:

Did everyone treat you as a unique person?

The decision to reference everyone in the HU^me is a direct result of views expressed within focus groups and national surveys. The vast majority of people expect that everyone, not just the care team, should treat them as a unique person.

What does it look like in practice?

As noted in our November 2022 nSight on The Power of ‘Doing’ Human Understanding, we held a series of diverse focus groups to find out. Participants highlighted many behavioral signs of Human Understanding – things like ‘recognize me as ME’ and ‘see the big picture of my life.’ Overall, their responses paint a clear picture of what consumers and patients are asking for:

It sounds simple but, in healthcare, even simple things can be hard to execute consistently. Data collected over the course of 2022 from our national Market Insights study confirms that there’s plenty of room for improvement – while twice as many people say it’s important to be treated as unique in healthcare compared to other services, only 38% say it happened in their most recent healthcare experience.

Moreover, Human Understanding is the #1 driver of Likelihood-to-Recommend and, thus, of Net Promoter Score (NPS) for health organizations. In fact, the odds of being a Promoter are 12 times higher for patients who report that everyone treated them as unique.

Detractors want Human Understanding

Data from our Experience surveys, most gathered within 48 hours of a clinical encounter, reinforce the importance of treating patients as unique people. The most prominent comments from nearly 325,000 Detractors provide yet another lens for seeing the value of connecting, listening, and partnering. Across Medical Practice and Inpatient settings, the lack of three things – emotional support, listening, and involvement of family/friends – appear to be a direct path to disappointing patients and generating Detractors.

Loyalty matters

Loyalty is critical to the health of health organizations: The average remaining lifetime spend for a 26-year-old healthcare consumer is $1.2 million.¹ Our national data shows an increase in loyalty at every point of the HU^me scale. A full 86% of respondents who report being treated as a unique person by their top-of-mind hospital profess loyalty to that organization. There is tangible value in Human Understanding.

The big picture

We examined the extent to which people across the continental U.S. feel they were treated as unique during their most recent healthcare experience. The darker-orange areas on this map indicate where people tend to have relatively high perceptions of Human Understanding and are likely to be more loyal to the health organization. Lighter areas signal more opportunity for market differentiation through Human Understanding. But there’s opportunity everywhere: While people in Louisiana reported the highest perception of Human Understanding, the proportion was less than 50% of respondents in that state.

Many consumers have come to perceive healthcare as generally lacking in Human Understanding. Indeed, healthcare has become a series of transactions – a problem that predates COVID and negatively affects all involved, whether they are seeking or delivering care. Even potentially promising initiatives such as the digital front door carry the risk of speeding up care transactions at the expense of relationships. To humanize care and strengthen loyalty, the focus on Human Understanding must be intentional and consistent.

A broad view of the patient is essential

As one component of the overall Human Understanding Program, NRC Health helps health organizations gather information about the context of patients’ lives – things like joys, pressures, goals, and preferences – directly from the patients themselves, and displays an at-a-glance view for care teams in the EHR. While there is a long-overdue push to tackle the social drivers of health in the U.S., there is little attention to what we call the personal drivers of health: lack of motivation or support, lack of time, feeling lonely or isolated.

When patients share their challenges, the personal drivers dwarf the social drivers in terms of frequency. And they are just as important to discuss and factor into any treatment plan, because these issues can have a major impact on health and self-care. Paying attention to what matters adds context and color to improve care.

The key is to go beyond the constraints of the traditional ‘How did we do?’ approach and broaden the focus to include ‘What are your needs?,’ ‘How are you doing?,’ and ‘How can we help?’ as appropriate at every touchpoint.

Human Understanding on the frontline

Of course, Human Understanding is important on both sides of the stethoscope – health organizations should be focusing on what matters to each member of their employed and affiliated staff as well.

Leaders can strengthen relationships with colleagues by demonstrating connection, listening, and pursuing partnership in everyday interactions. Building an intentional culture that demonstrates Human Understanding for all involved – via behavior, not just words – sets the stage to take on Healthcare’s Headwinds and challenge the ‘new normal’ by charting a course toward the New Awesome.

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In 2022, the Human Understanding Institute hosted a series of eight Summits across the country, engaging experience and marketing leaders from 98 health organizations in the movement to focus on what matters to patients, families, and care teams. Toward the end of the year, we held an invitational Human Understanding Summit with experience leaders from major medical centers.

The very first response to a question about innovation was, “Just getting back to basics would be transformative.”

While everyone rallied around this sentiment, no one was talking about moving backward. The aim was to create a strong foundation for contemporary care by prioritizing Human Understanding at every touchpoint. Together with the Human Understanding Institute, the group prioritized a short list of universal strategies to reframe attention on what matters most:

1. ALIGNMENT/BUY-IN

• Broaden the conversation to recognize that experience extends beyond any one clinical encounter and beyond the care setting in general
• Position experience as shaped by how we do everything – not ‘one more thing to do’
• Illustrate connection to other strategic priorities
  • Examples: quality, safety, left without being seen, loyalty, revenue
• Emphasize what scores are meant to reflect instead of just the scores themselves
• Focus on patient comments to humanize improvement opportunities

2. HUMAN CONNECTION

• Make human connection an expectation for standard work in all interactions with patients, families, and colleagues
• Use effective communication behaviors to support Human Understanding
  • Use relational statements/questions (‘How are you doing?,’ ‘I hear you,’ ‘How can I help?’)
  • Non-verbal factors (eye contact, tone of voice)
• Leverage tools that help make behaviors authentic and systematic
  • Examples: engaging in purposeful rounding; summarizing patient context in the EHR

3. FRONTLINE FOCUS

• Demonstrate that experience is important on both sides of the stethoscope by going beyond engagement surveys to focus on what matters to employees as individuals
• Develop a comprehensive strategy to address employee well-being and foster mutual respect
• Adjust workflows and workloads – with frontline input – to make it easier to do the right thing
• Use patient comments to recognize care providers – it’s fuel for the soul

The strategies of Connect with me, Listen to me, and Partner with me factor into each of the fundamentals. To broaden the impact, the Human Understanding Institute has created a set of resources with tactics that support the work.

Thinking broad and going deep

Patients, consumers, employees, and providers — people in general – think about their own experience in broad terms. Clinical encounters are a vitally important component of experience, but health organizations must treat what matters before, during, after, and beyond care more holistically by gaining a deeper understanding of the various touchpoints involved. Basing action on expectations and feedback is far more valuable than making assumptions about what people need.

PATIENTS: THE SPECTRUM OF EXPERIENCE

• “The registration time is fantastic. Very efficient.”
• “The call center person was unable to answer easy questions on topics such as parking. She also gave incorrect copayment information to me.”
• “In my recent experience, it was very hard to reach anyone by phone to get an appointment (long hold).”
• “There was only one person in the registration station, and it took the line almost an hour to get through it. Only one person checking you in. It was just a disaster. Once in, the people were great, but that intro line is really bad.”
• “The person drawing the blood was pleasant with a great personality.”
• “This was a video visit. The nurse first called me by phone to connect the appointment and before hanging up she stated that she would call me immediately following my meeting with the doctor. At the end of my video visit, he stated that his nurse would call me after he disconnected to follow up with the appointment. I waited one hour, and I received NO follow-up call from the nurse.”
• “I am grateful to be able to get the care I need with such a great caregiver. She and others like her are the reason I am able to enjoy a good quality of life in my 80s!”
• “Doctor did not explain what is going on with the arthritis or what it means to my lifestyle in the future. I would describe his manner as perfunctory rather than personal and in depth.”
• “She took time to explain to me the procedure I wanted, talk about the benefits and drawbacks to selecting each option, and make a recommendation that suited my lifestyle.”
• “I asked three different departments to explain billing. I was promised a call back, but it never happened.”

PROVIDERS: A COMMITMENT TO CARE

• “I felt our clinic went above and beyond to help our patients during COVID. Our management allowed us the ability to be creative in finding resources to help our patients, setting up the clinic to best meet the needs of our providers and patients and creating an environment that felt home-like since we spent so many hours working in the clinic each week.”
• “The implementation of the EHR in our outpatient setting has been a struggle. It takes staff away from patient care and is more focused on placing them behind a computer checking people in and out of the EHR. I would like to see changes made to this process that puts the focus back on patient care.”

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The original Triple Aim (enhance care, improve health, reduce cost) as well as the subsequent Quadruple Aim (adding care-team well-being) and Quintuple Aim (adding health equity) all include quality as a core component of the care experience. Quality drives health outcomes as well as a positive reputation and loyal patient base.

The Institute of Medicine (IOM), which advises the nation on matters of health and medicine, established six domains of quality: Safe, Effective, Patient-centered, Timely, Efficient, and Equitable.

Only three of the IOM domains signal quality for more than half of the 121,315 healthcare consumers who had a healthcare encounter within 12 months of their response: Effectiveness, Patient-centeredness, and Safety. The other three IOM domains (Efficiency, Equity, and Timeliness) are certainly essential elements of care. The point is that most consumers don’t see them as aspects of quality per se.

Paying attention to what matters yielded a powerful insight by surfacing two additional domains – not explicitly outlined in the IOM report – that healthcare leaders should highlight in their quality journey: Communication and Cleanliness. These were endorsed by more than half of consumers, meeting the same threshold as Effectiveness, Patient-centeredness, and Safety.

This is the lens through which consumers see quality. Interestingly, Patient-centeredness and Communication reflect and reinforce the importance of Human Understanding. All five of these priority domains are important to keep in mind when reading The Governance Institute Health System Quality Honor Roll 2022, which focused on the latest CMS Star Ratings to determine technical quality performance and used NRC Health’s Market Insights data to gauge consumer perception of quality.

Recognizing different viewpoints

It is crucial to bear in mind that perceptions of quality vary by both age and sex. Regardless of age group, women place more weight on each aspect of quality than do men. And regardless of sex, a greater proportion of consumers at least 45 years old endorse each aspect of quality than do their younger counterparts (18–44 years old).

Looking at the intersection of age and sex, younger males ascribed less weight to all aspects of quality compared to younger females. For example, Effectiveness was the most salient component of quality for younger men but was still only endorsed by 40% of respondents, compared to 53% for younger women. For younger men, there was no instance in which more than 50% agreed that a particular facet conveyed quality, whereas more than half of younger women conceptualized quality as Cleanliness, Communication, Effectiveness, Patient-centeredness, and Safety.

This pattern changed for both older men and women. When looking at men 45 and over, at least half endorsed the same five aspects of quality that were highlighted by younger women. And for older women, the proportion highlighting Cleanliness, Communication, Effectiveness, Patient-centeredness, and Safety jumped to over 60%, with Cleanliness and Patient-centeredness both reaching almost 70%. More than half of the women in this group also pointed to Efficiency, Teamwork, Technology, and Timeliness as markers of quality.

The bottom line: Delivering quality care is important irrespective of group characteristics like age and sex. While perceptions may change for individuals and groups, Cleanliness, Communication, Effectiveness, Patient-centeredness, and Safety are the most prominent domains of quality from the patient point of view – a view that comes into sharper focus as people gain experience with healthcare.

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We see Human Understanding as a direct path to equity – a crucial marker of excellent, ethical care. The logic is straightforward: If patients are treated as unique people, they are more likely to receive care that fits within the context of their lives and helps them achieve their health-related goals. While the n=1 view is most important, stratifying data can help illuminate the extent to which patient experiences vary by demographic characteristics. The first step to addressing gaps is knowing they exist.

Preferred language

NRC Health data revealed that in 2022, Spanish-speaking patients rated Provider Listened 16.9% lower and Trust in Provider 17.5% lower than did English-speaking patients. Preferred language is associated with substantial gaps in the delivery and experience of care.

Process gaps are likely to have real-world consequences in terms of outcomes. We analyzed more than 300,000 discharge follow-up calls and found that, during those calls, Spanish-speaking respondents triggered an alert 43% of the time compared to 27% for English speakers. While this differential should raise flags in and of itself, the problem is amplified by the fact that organizations report resolving alerts for Spanish speakers at a markedly lower rate than they do for English speakers.

When these facts are taken together, we see that Spanish speakers are more likely to leave healthcare encounters feeling unheard, report having significantly lower trust in providers, tend to have more ‘alert-worthy’ issues after discharge, and have a greater percentage of unresolved concerns. The confluence of these factors can result in disengagement, poor outcomes, and costly readmissions, all with an associated long-term impact.

Awareness is essential. Stratifying experience data clearly reveals the need for a concerted effort to better address the healthcare needs of Spanish-speaking patients. But designing interventions that treat Spanish speakers as a monolithic group moves us further away from Human Understanding. The key to ensuring excellence for all patients is to monitor aggregate demographic trends through an equity lens, highlighting gaps and looking to solve systems problems while treating each patient as a unique person in every interaction to close the gaps.

Race/Ethnicity

In addition to preferred language, there are multiple points of focus and intersection when it comes to examining equity (e.g., sex, gender, age, race/ethnicity). Race and ethnicity are a major theme of work on Diversity, Equity, Inclusion & Belonging at hospitals and health systems across the country. Our data shows there is still considerable work to be done when it comes to demonstrating listening and building trust.

81% of patients identifying as White reported that their provider listened to them. However, the proportion of people who reported top-box scores for listening fell for those identifying as Hispanic (71%), Black (73%), Native American (73%), Asian (74%), and Hawaiian/Pacific Islander (76%). Trust was higher in each group but followed a similar pattern.

This type of analysis is the foundation for action. Deciding to act, setting a disciplined course of action, tracking progress to calibrate process, and managing accountability for outcomes are equally important. Rather than instituting training programs that may run the risk of stereotyping patients of certain groups, the most productive strategy is to improve care for all patients by paying attention to what matters to each person. A programmatic approach to Human Understanding can transform care in everyday practice.

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Benchmarks provide a means for organizations to compare their performance against industry standards or competitors’ performance. Used appropriately, they can help set context, track progress, and identify areas for strategic action. There is no question that benchmarks should be in the toolbox when it comes to monitoring organizational health.

However, overreliance on benchmarks can be extremely problematic. One consideration is choosing the comparison group. Should it be based on hospital size, system size, type of system, patient base, location, or some combination of the above? Organizations differ on so many variables that it can be hard to benchmark accurately. When ‘apples to apples’ comparisons prove difficult, leaders may be satisfied with ‘apples to oranges.’ The key is to keep the comparison in perspective and avoid comparing ‘apples to Saturdays.’

Choosing the metric itself is equally important: The right metric can be a useful rallying point, while the wrong one diverts precious organizational energy. Regardless of the metric, a myopic approach to benchmarks presents the danger of chasing scores instead of focusing on the behaviors and outcomes that the scores are meant to represent.

While benchmarks have their place, it is perhaps more important to focus on actual improvement within the organization itself – to ‘benchmark against yourself.’ It is entirely possible to maintain or even improve on a percentile basis if performance is declining, as long as other organizations are declining at the same rate or faster. Conversely, healthcare organizations can make meaningful progress on initiatives that improve real patient outcomes and lives but lose sight of the benefits they were generating if performance falls short against an external benchmark.

Benchmarks are not enough

Moreover, some organizations take an ‘all or nothing’ stance in utilizing benchmarks to incentivize team member behavior. This runs the risk of creating the opposite effect – a morale-sapping disincentive if the goal is unrealistic or fails to recognize meaningful gains that fall short of a target. Imagine a physician who improves the ‘provider listened’ score by 23 percentage points with the help of a coaching program but does not break the organizational threshold of, say, the 80th percentile because so many providers are clustered at the top. Without a parallel focus on raw-score improvement and other performance metrics, benchmarks can distract attention instead of focusing organizational and personal effort.

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For additional context and strategic insight, we worked with the NRC Health Research team to identify a set of meaningful industry trends worthy of consideration in the year ahead.

TREND: Community Insights – Top 10 Topics

A human-centered design approach to understanding issues and solving problems starts with listening to the people affected by them. Forward-leaning health systems are turning to crowdsourcing solutions like NRC Health’s Community Insights to tap into the voice of patient communities and consumer groups as well as those of their own employees and providers. In addition to revealing essential insights, this practice can increase connection, engagement, and loyalty.

TREND: Telehealth Use Over Time

Telehealth visits grew 1000x after the pandemic hit, peaking in 2021 and moderating over the course of the past year. It is clear that telehealth has broken free from pre-pandemic restraints and become a critical part of the health-system access strategy. When it comes to hardwiring consistent experiences across the consumer journey, telehealth touchpoints cannot be an afterthought.

TREND: Retail Clinic Use

Retail clinics have continued to multiply in recent years as consumers indicate increasing openness to the concept. Health systems need to be aware of these new access points in their communities and choose a path forward. Whether the ideal strategy is competition, collaboration, or co-opetition, retail care has to factor into the strategic vision for many health organizations.

TREND: Emergency Department Wait Time Impacts

For many hospitals and health systems, the ED remains the primary door through which patients enter, and it’s a powerful first experience. Staffing shortages – combined with the increased volume of patients needing care for COVID, RSV, and flu – have led to abnormally long wait times. Unsurprisingly, this amplified negative comments about waiting and took its toll on NPS. Our October nSight on Understanding Perceptions about Wait Times offers ideas for reducing the frustration associated with waiting.

TREND: Facility NPS vs. Provider NPS

Since 2019, provider NPS has risen steadily while facility NPS gains have slowed, and the gap widened in 2022. This trend points to the rising importance of relationships and human connection as a driver of loyalty. Systems should consider strategies and tools that recognize and make room for meaningful connections that promise to restore the sanctity of the patient-provider relationship.

TREND: Inpatient Self-reported Health Rating

It has been well documented that the physical and mental health of patients has been declining since the start of the pandemic for myriad reasons. Indeed, self-reported physical and mental health ratings of ‘fair’ or ‘poor’ have increased significantly since 2020. This self-awareness may create an opportunity for health systems to change the tide: With a broader recognition of their own health challenges, consumers maybe be more likely to engage with brands that ‘meet them where they are.’

Worsened physical health has been documented by the American Hospital Association, and worsened mental health has been documented by the World Health Organization, as well as other organizations.

TREND: Post-discharge Alerts on the Rise

The percentage of patients needing follow-up after-discharge has increased markedly over the last four years in all care settings. Unaddressed concerns after a healthcare encounter can lead to disengagement, poor outcomes, and costly readmissions, with an associated long-term impact on brand.

The number-one alert for all care settings – by a wide margin – is related to understanding discharge instructions; followed by service issues, inability to access follow-up care, and medication questions. These process-oriented barriers are all within the control of the health system: It is far more effective to prevent problems and preempt questions than to play catch-up after the patient leaves the care setting.

TREND: Top 10 Factors for Selecting a Doctor’s Office

As highlighted in our December nSight – A Close Look at Access to Care, there are four main aspects of access: Getting Coverage (insurance), Getting There (location), Getting In (availability), and Getting Seen (waiting). Each one functions as a gate to seeking and receiving care. Access is a true differentiator: Five of the top 10 selection factors (covered by my insurance, office location, appointment availability, short in-office wait times, flexible hours) are directly related to access. Moreover, despite unprecedented turmoil over the past few years, this picture has remained constant.

TREND: Hospital Website Use

After a drop in 2020, consumers’ use of hospital and healthcare provider websites has continued its climb, making these resources a critical connection point for health systems. Importantly, consumers are using these websites just as they do when shopping for other services: first searching, then reading reviews, and finally diving deeper so they know what to expect. Strategically designed sites will reduce friction at this launch point in the journey by ensuring that provider search is front-and-center, and that the results contain useful information, based on an understanding of what people are seeking.