It's an incredible promise for a busy emergency room to make: Patients will be seen within 15 minutes by a nurse and within 30 minutes by a physician or the hospital pays your bill.
But that's precisely the high hurdle that Robert Wood Johnson University Hospital has set for itself. Since the New Brunswick, N.J., teaching hospital and trauma center implemented its service guarantee more than five months ago, it has treated some 16,000 emergency patients, only one of whom has asked for money back. The hospital simply canceled the patient's bill.
Over the past 10 to 15 years, various hospitals have offered service guarantees, but few have succeeded. Some were simply allowed to fizzle out.
Calls to the American Society of Hospital Marketing and Public Relations, the Patient Focused Care Association, the Advisory Board and other industry consultants revealed there are fewer than two dozen hospitals that offer such a program.
Mission Oaks Hospital in Los Gatos, Calif., guaranteed that if emergency room patients weren't seen within five minutes, their bills would be reduced by 25%. But after the program's inception, Mission Oaks changed hands. Its new owner, Good Samaritan Health System, closed emergency services at the hospital in 1990.
Edmond (Okla.) Regional Medical Center discontinued its program after a year, and Freeman Hospital in Joplin, Mo., and Westlake Community Hospital in Melrose Park, Ill., no longer offer written guarantees.
Compared with the patient satisfaction promises some hospitals still offer, Robert Wood Johnson's guarantee appears to exceed industry standards and puts its bottom line at risk. You might even call it "extraordinary."
Christopher W.L. Hart, author of the 1993 book Extraordinary Guarantees-published by the American Management Association, New York-and president of the Boston-based Spire Group, helps companies design guarantees that identify and resolve quality problems, improve customer satisfaction and boost revenues through the promise of a specific payout.
The payout acts as a catalyst for identifying problems that need to be resolved, Hart said. "Offering an extraordinary guarantee is like turning up the pressure on the hose: It exposes the leaks," he said.
As a former professor at Harvard and Cornell universities and examiner for the Malcolm Baldridge National Quality Award, Hart has spent many years studying guarantees. He acknowledges that they have received little attention in the healthcare services field.
Healthcare is so complex and malpractice-wary that people think there's nothing that can be guaranteed, he said. Medical professionals often shy away from anything that smacks of marketing, he added.
When Hart followed up on Westlake's program in August 1993 he was told the administrators who set up the program no longer worked there. Hart was told Westlake decided to yank the guarantee because of concerns that patients would complain for spurious reasons, that patients might cheat and demand money back, and that services couldn't be unconditionally guaranteed because workers make mistakes, he said.
No commitment."In a risk-averse organization like a hospital, it's very difficult to get (commitment) to the idea that offering an extraordinary guarantee is indeed a litmus test" of its commitment to patients, he said.
While the barriers are daunting, such iron-clad promises carry great potential in healthcare, Hart asserted. "The only reason it would be inappropriate for healthcare providers to offer an extraordinary guarantee is if they were to guarantee something that they couldn't," such as medical outcomes, he explained.
Robert Wood Johnson's guarantee grew out of an initiative begun two years ago to reduce long waits in the emergency room. By doubling the ER's size and adding staff, administrators hoped to reduce complaints and walkouts.
The changes helped. The hospital received fewer written complaints, the number of walkouts declined to 50 per month from 180 and the average wait of 30 minutes was considered an improvement.
But the hospital's reputation for long ER waits hadn't changed. "The patient who's waiting for two hours is not interested in the fact that other patients got seen in 15 minutes," said Harvey A. Holzberg, the hospital's president and chief executive officer. Hospital officials had to find a way to get the word out that things were better. "The problem was one that I think a lot of hospitals have: How do you let people know you've accomplished (shorter waiting times)?" Holzberg said.
That's when the idea for the guarantee surfaced. Holzberg challenged his staff to find a way to see patients within 15 minutes. At the time, it was taking 15 minutes just to register patients.
To meet the challenge, the hospital hired a "floating" registrar who followed patients with a clipboard and registered them as they moved through the ER, and hired a second triage nurse. Physicians were assigned to shorter shifts that allowed them to stay an hour or so later if necessary. Physicians also started carrying beepers, and a budget of $1,000 a month was allotted to pay for extra hours.
"It ended up being a re-engineering process, but it didn't start out that way," Holzberg acknowledged. Since December 1994 the hospital has experienced a 15% increase in patient flow, but walkouts have been eliminated, he said. While 45% of patients used to be in and out of the ER in two hours, that figure has risen to 70%.
In March the hospital began advertising its guarantee. Convinced that patients' expectations would be met, no budget was established for paybacks. There also were no stipulations about waiting times should a disaster occur and overload the ER. "The definition of what patient gets their money back is any patient who asks for it," Holzberg said. "Any money we give back we eat."
If Holzberg's math is right, the hospital will make money on the program. Registration improvements cost $60,000 and physician overtime is $1,000 a month. That's offset by additional revenues estimated at $150,000 a month, or $1.8 million a year, that had been lost on the 50 people who used to walk out of the ER each month. Robert Wood Johnson believes it's the only hospital offering such a guarantee in an emergency room.
Reid Hospital and Health Care Services in Richmond, Ind., guarantees nonmedical services provided by all hospital personnel, but excludes the services of physicians, dentists and allied health professionals.
Patients who aren't satisfied need to advise the hospital within 24 hours of receiving a service. If the problem isn't corrected within 12 hours, the patient's account will be credited with the cost of the specific services. It specifically excludes from its policy waits for services while more seriously ill patients are treated.
Such a program doesn't meet Hart's definition of an extraordinary guarantee because of all the strings attached.
Hart said he's currently working with two healthcare providers that hope to offer service guarantees, "not as a trick or marketing tool.....but as a catalyst" for better service. He expects to see the pace of such offers pick up as healthcare providers scramble to distinguish themselves in an increasingly competitive marketplace.
A Blues tries its hand.
It appears the race has begun. In May 1994 the eight health centers operated by Blue Cross and Blue Shield of Massachusetts announced a promise to avoid inconvenient delays, treat patients in a competent, compassionate way and provide information to help improve patient health and lifestyle. If not completely satisfied with the services provided, patients may receive a refund of their out-of-pocket costs.
The program was conceived as a way to differentiate the health centers in a competitive market, said Colleen Martin, a marketing manager for the Blues' health center division. "It was decided that the service guarantee would be a great breakthrough strategy," she said.
Last year, just 621 refunds were made out of 20,000 potential patient encounters a week. For the first three months of 1995, 210 have invoked the guarantee. And patient satisfaction surveys show that the dissatisfaction rate has dropped to 3% from 6% when the program started. Of the people who invoked the guarantee, 97% plan to re-enroll with the Blues plan.
Because the invocation rate is so low compared with an average rate of 2.5% for all service industries, plan officials are considering another promotion to get word of the guarantee out. Meanwhile, Martin has received calls from at least two Texas hospitals interested in the program and Blue Cross of Western Pennsylvania, which is considering a similar guarantee for the health centers it is building.
Contrary to industry concerns, only two of its health center customers were found to make unreasonable complaints, Martin said. "Inevitably, what people want from you is good service," she concluded.