Executive summary

As health care delivery becomes more competitive, health We believe the Patient Experience can be the basis of a
care providers would be wise to consider shifting their successful strategy for health care organizations. This
focus to attracting and retaining patients. Patients have strategy requires providers to reassess their organizations
more choice of hospitals and information available to from the perspective of the patient. The desired patient
them now than ever before, and they are increasingly experience should then be made operational through
acting as consumers. This makes gaining customer a deliberate plan of tactical and infrastructure changes
loyalty as important as managing costs and revenues, that can help drive stakeholder value while achieving the
and hospitals should innovate to retain customers and desired patient experience.
maintain protability. Making a strategic choice to provide
patients with the best experience is a proactive and
sustainable way to create competitive advantage in this
dynamic marketplace. While this strategic decision can
positively impact the nancial health of the organization,
for most systems, making this decision a reality is not
without signicant effort.

The model for focusing on the patient experience already

exists in consumer businesses that have pursued a
distinctive customer experience. Widely-known consumer-
oriented organizations such as Disney, American Express,
The Ritz-Carlton, Starbucks, USAA and FedEx focus
on delivering an experience targeted at the evolving
behaviors, needs and expectations of their customers.
Delivering on a customer experience that is truly distinct
from the competition can help an organization to increase
market share by providing a basis for attracting and
retaining protable customers.

1
 Your Patients Are ConsumersHealth Care is a
consumer-oriented business
What do consumer-oriented businesses have to do with
health care? Your organization provides valuable life-saving
and life-enhancing services, not entertainment. Yet, like it
or not, there is competition even for saving lives, and your
patients and potential patients are living in a consumers
world.
Nearly 40% of the 2008 Survey of Health Care Consumers conducted by the Deloitte
Center for Health Solutions indicate that they would be willing to travel for care,
either to a hospital they perceive to be of a higher quality or to save money for an
elective procedure while 20% indicate that they have already made such a choice.
While quality can assume different meanings, it is consumers perception of quality
however they dene it that is important in this context.
Patients increasingly engage in traditional consumer
behaviors when making health care decisions. With
comparative data about providers more readily available
and health plans offering greater choice, patients are more
willing to switch based on a perceived value difference
between providers.
What is The Patient Experience?
A patients experience is broader than just the clinical
aspects of care (Did I receive the most appropriate care
for my condition? Was the outcome the best possible?);
all of the various non-clinical interactions also inform
their experience. Because patients are often at their most
vulnerable while receiving health care services, each
interaction takes on added signicance. All of these
interactions, or touch points, are the basis of The
Patient Experience. Each touch point offers the health
care provider the opportunity to deliver unique benets to
the patient and to create a platform for differentiation and
competitive advantage.
Non-clinical touch points can far outnumber those that
a patient has with a physician or caregiver. They also
are often the rst and last impression a patient has of
the organization. Figure 1 illustrates a set of non-clinical
touch points for one patients visit. These activities can
distinguish a patients experience when done efciently
The Patient Experience refers to the quality and value
of all of the interactionsdirect and indirect, clinical
and non-clinicalspanning the entire duration of the
patient/provider relationship.

Figure 1. A subset of touch points related to the Revenue Cycle

Charge
Scheduling Financial Financial Registration Case Discharge HIM Pricing Claims Denial Account Payment
Capture
/Pre-reg. clearance counseling management operations processing management resolution posting
and Entry

Physician ofce or
patient schedules
a patient appoint-
ment: Scheduling
sends an appoint-
ment itinerary with
date, location,
provider and perti-
nent appointment
information
Financial coun- Case manager Biller submits claim Patient contacts
selor contacts the contacts patient to to the insurer on customer service with
patient to arrange discuss initial dis- behalf of the patient inquiries regarding
a payment plan charge plans, patient their health plan
or to complete liability, etc. coverage and reim-
medicaid/charity bursement rates
applications

A customer service represen- Registrar checks in patient Patient presents to Release Patient contacts Patient contacts
tative or nancial counselor con- via face to face, kiosk or of Information department customer service to customer service
tacts patient to communicate tablet and collects to request copies of medical inquire about denied to inquire about
patient liability, collect patient signatures for consent records claim and self pay payment amount
payments or arrange for collec- and ABN as necessary balance and where to
tion/payment plans send payment
2009 Deloitte Development LLC. All rights reserved.

2
and effectively from the patients perspective. High-quality
clinical care is still the rst priority, necessary simply to
compete. However, when a patient must choose between
two providers with equally high-quality clinical care,
patients likely will choose the one that provides unique
value in all of their other interactions, the one that they
believe provides the best experience. Many of those
interactions deal with registration, billing and collections
or what are known as revenue cycle touch points to
hospitals.
Using a Customer Experience to create The
Patient Experience
To create a differentiable Patient Experience, health care
providers should cultivate the customer experience
capabilities successfully employed by consumer-oriented
businesses such as:
A clear vision and strategy of delivering an exceptional
customer experience based on a deep understanding of
the service expectations of their customers;
Internal delivery capabilities, both operational and
technology-enabled, that are focused on delivering the
envisioned experience and agile enough to evolve with
the customer;
A structure and culture that empowers and rewards
employees for superior delivery;
Measurement capabilities to identify and track
customers evolving service expectations.
Health care providers should consider developing these
Customer Experience Capabilities in their efforts to
successfully create and deliver their targeted patient
experiences.
Delivering a differentiated Patient Experience
a strategic choice for Novant Health
A Patient Experience strategy begins with the denition
of a clear vision that is linked to the core value proposition
and corporate objectives of the organization: What will
a differentiated patient experience look and feel like?
How will it meet the needs of patients? What is the
organization capable of delivering? Are the nancial and
competitive benets sufcient to drive change? Once the
vision has been dened, the organization should identify
and commit to the series of investments and capability
improvements required to make the vision real.
In 2008, Novant Health, Inc, an integrated health
care system serving more than 3.5 million people in
North Carolina and the surrounding region, decided
to pursue a strategic advantage by changing the way
health care is delivered. Novants goal was to create
a remarkable patient experience in every dimension,
every time and to be the organization against which
others are judged. A Revenue Cycle-focused team
was one of the eighteen teams created across clinical
and non-clinical operations to achieve the vision of a
remarkable patient experience.
What do patients expect from their health care
experience?
In a patient experience strategy, the organization should
rst adopt a patient perspective. Consumer-oriented
businesses often rely on customer segmentation
to understand the behaviors, attitudes, needs and
expectations of different types of customers. They use
the resulting segments to tailor their services to specic
customer groups in order to help improve prots. Such
value-maximizing customer segmentation decisions may
seem counter to the health care providers mission to
serve. Nonetheless, by offering deeper insight into what
patients value, segmentation analysis can enable providers
to deliver superior experiences to all of their patients.
3
 In a recent survey1 of health care consumers, ve themes
emerged around patients expectations of their health care
experiences:
1. Personalization: Patients want their health care
provider to know who they are and what they need as
individuals
2. Security: Patients expect their privacy and security to
be protected
3. Operates Like a Business: Patients want their health
care providers to be easy to work with
4. Dependability: Patients want predictability,
consistency and dependability
5. Transparency: Patients, and their families, want to
see and understand what is happening to them
Understanding these ve attributes and how they relate
to touch points, for specic patient populations, is the rst
step in making the strategic choice to deliver an enhanced
patient experience. Armed with a thorough understanding
of patient expectations and experiences, the organization
can begin to develop a compelling vision of the future
state.
A key component of Novants journey to create their
ideal patient experience was improving all revenue
cycle functions, or the scheduling, registering and
billing of patients. Novant recognized the importance
of the revenue cycle touch points in the overall patient
experience, as revenue cycle staff often have the rst and
last contacts with patients.
4
The Novant Revenue Cycle team used a Voice of the
Customer (VOC) approach to dene the needs and
values of the Novant patient population. Through
touch point interviews, employee focus groups, a
cross-departmental leadership visioning retreat, and
patient segmentation exercises, ve themes emerged
that formed the basis of patients expectations for
their experiences. The team focused on identifying
valuable patient-facing services that appeal (on
different levels) to each of Novants patient
segments.
The VOC insight was translated into a clear and
compelling vision of the Remarkable Patient
Experience by illustrating an actual patients
perspective. In this case, the illustration was a future-
state narrative about a patient named Newman
and his experience at each touch point as he seeks
treatment for chronic heartburn. The narrative
made the Patient Experience tangible, both for
communicating the vision and for identifying the
capabilities required for delivery.
What is the organization capable of delivering?
Delivering a differentiated patient experience requires
the organization to optimize against a broader set
of objectives than simple cost management. Many
patients expect their health care providers to operate
like a business with the predictability, consistency and
dependability that they have come to expect from the
retail and service organizations with which they do
business every day. It is important that the organization
have the internal capabilitiescultural, operational and
technological, and the human capitalto meet, and
exceed, the expectations of their customers.
The Revenue Cycle team used the Customer
Experience Capability Model (CE Model)2 to assess
Novants customer experience capabilities against
those of organizations known for delivering superior
and targeted customer experiences. This framework
allowed Novant to identify the basic capabilities
required to support a differentiated customer
experience.
The team also assessed Novants ability to provide
operational and workow excellence in support
of the customer experience. To do this, they used
the Revenue Cycle Maturity Model,3 which uses
productivity, operational and nancial metrics to
measure key performance along the spectrum of the
core revenue cycle functions.
These capability assessments immediately revealed
several gaps along multiple dimensions that Novant
needed to close to achieve its vision: technology
(enterprise-wide view of all patient data and activity,
web-services), people (adopting the roles of registrar,
comforter, nancial counselor, etc.) and processes
(hospital services run with predictable timing, delivery
and outcomes).
How does the organization move toward delivering
what the patient wants?
With a clear vision of the future patient experience and
the results of the capability analyses, the organization can
set about identifying the activities necessary to deliver
the differentiated patient experience. In most cases, the
list will be long and threaten to obscure the clear vision.
Where should you begin? How will you stay engaged and
aligned? How will you know whether the activities are
improving the patient experience?
Patients perceptions of their health care experiences are
shaped along four dimensions (Figure 2). We believe a
Comparative Performance Analysis can help a provider
organization understand its performance along each
of these dimensions. Deciencies in any of these areas
can highlight those activities that may have a signicant
impact on the Patient Experience. Metrics within each
dimension can be compared to competitors and to
effective industry practices in order to identify the activities
that can maximize the tangible progress toward creating
a competitive advantage. These measures also provide a
baseline and a framework for ongoing assessment of the
organizations progress.
5
 Figure 2. The Drivers of Patient Perception
Clinical Quality
Patients perception of their customer
experience is positively correlated with
clinical quality
Clinical
Did I receive the appropriate care for Quality
my condition?
Did I get the best outcome possible?
Customer Approval
The feedback that customers provide
about their experiences is clearly a
key indicator of the quality of the cus- Customer
Approval
tomer experience but should not be
used as the sole measure of success
2009 Deloitte Development LLC. All rights reserved.
Comparative performance analysis of patient
perception metrics:
Clinical Quality metrics have two elements: the
patients perception of clinical care and a standardized
measurement of clinical outcomes. The Center for
Medicare Services (CMS) Hospital Consumer Assessment
of Healthcare Providers Survey (HCAHPS) is the rst
standardized, national tool for measuring and ranking
organizations relative to their patients perception of
clinical quality. Clinical outcomes can be tracked and
compared directly using standard metrics for service-
specic outcomes and can be found online on sites such
as JCAHOs Quality Check website.
Customer Approval metrics are used to track the patient
experience, both clinical and non-clinical. Many large
health care organizations already perform some level of
customer satisfaction survey. They also can rank their
performance against competitors, locally and nationally,
using a standardized measurement methodology. To
effectively understand patient perceptions, survey tools
should address the whole spectrum of service delivery.
6
Operational/Financial
Performance
An organizations ability to both run
Operational/ efciently and to make the necessary
Financial investments in people, process and
Performance technology is positively correlated
with their customers experience
Employee Engagement
Employees who feel emotionally
Employee attached to their employers and
empowered to move the organiza-
Engagement
tion forward can have a signicant
impact on customers perceptions of
their experience
Employee Engagement metrics are used to track the
employees sense of commitment to the organization
and alignment with the organizations strategy and
vision. The employee is the face of the organization and
manages the major patient touch points. Standardized
comparative tools, such as Fortune Magazines 100 Best
Companies to Work For, measure employee satisfaction
around major factors such as diversity, pay, training
and skill development, benets and work life balance.
Regular internal assessments can provide further insight
into employee perception and alignment with respect to
position, role and the overall organization.
Operational/Financial Performance metrics reect
the organizations ability to support and maintain the
changes needed to deliver on patient experience while
still remaining protable and competitive. Many of these
metrics are traditional metrics hospitals track on a regular
basis. Figure 3 shows a subset of possible metrics; the
appropriate metrics should be specic to a hospitals goals
and reporting guidelines.
Figure 3. Traditional operational and nancial performance metrics that support delivery of a
differentiated patient experience.

Financial Performance

Revenue Management Asset Efciency and Cost Containment Results

Accounts Receivable Days/
Aging Distribution
Daily Cash Collections
Cash Factor (Net to Gross
Ratio)
Net Revenue/Denial Recovery
Gross and Net Revenue/
Adjusted Patient Day
Protability
Net Income and Operating
Margin
Total Asset Turnover
Total and Operating Margin
(value/%)
Return on Assets %
Salary/Non Salary Expense
Ratios
Capital Overhead Distribution
and Percent
Cost/Adjusted Patient Day
Cost to Collect
Financial Stability and Viability
Available funds to support
process and technology
improvements
Focus towards enhancing the
RPE

Operational Performance

Capacity, Utilization and
Stafng
Bed Turnover/Availability Rate
ER Diversion Rate
Average Daily Census,
Occupancy Rate and LOS
MD/Nursing Stafng Ratios
Stafng Turnover
Revenue Cycle Metrics
Financial Clearance Rates/
Timeliness
Productivity Ratios and Cost to
Collect
Patient Liability/Collection Rate
Days to Collect
Patient Touch Point Metrics
Patient Wait Times/ED Process-
ing Times
Call Center Time to Answer
and Abandon Rate
Appointment Availability/Time
to Next Available Service
Online Accessibility Ratio
Results
Efcient work ows to support
seamless processes and acces-
sibility
Patient focused touch points
that address the patient need
Provision of patient friendly
options for navigating the
organization

Adjusted Patient Day

2009 Deloitte Development LLC. All rights reserved.

The Patient Experience Roadmap can help keep the
organization on track for protable, sustainable,
competitive advantage
The Patient Experience Roadmap is a prioritized
outline of all of the capability-building activities required
to deliver the envisioned patient experience. Within
the roadmap, activities are prioritized to help maximize
the tangible progress toward creating a competitive
advantage and to have a signicant impact on improving
the Patient Experience.
As with any strategic choice, the patient experience
activities should also create value for the organizations
stakeholders. To conrm that The Patient Experience
Roadmap meets this third objective, the organization
should understand how the key activities in the roadmap
will be completed and the costs and benets to doing so.
An Execution Plan includes the high level work plan,
projected timeline, estimated resources, ancillary support
areas and the dependencies required to implement the
roadmap. A Business Case supports the nancial and
competitive benets sufciently to drive the necessary
changes through the organization and to sustain the
results long term.
Throughout implementation and thereafter, the
organization can return to the Comparative Performance
Analysis to assess its performance. Outperforming the
competition along all four dimensions can be equated
with providing a differentiated Patient Experience. This
analysis will provide ongoing guidance for prioritizing
the activities that may have a signicant impact on
the organizations competitive advantage, positively
impact the Patients Experience and create value for the
organizations stakeholders.
7
 The Novant teams created a multi-year Patient
Experience Roadmap to bridge the gaps between
their current and future state. Deloitte worked with
the teams to help them in their efforts to identify the
priorities and sequence of activities and the business
case for completion, which indicated a substantial
return on investment. The completed roadmap
included a timeline, sequence and priority matrix for
six key initiatives:
1. Hub and spoke customer service delivery model
Establishing a retail-like delivery model for all
revenue cycle services
2. Transaction processing optimization Focusing
on optimization and automation of critical, non-
patient facing operations
3. Differentiated HR operating model Building the
necessary human resources foundation for delivery
of the Remarkable Patient Experience
4. Enterprise technology integration Integrating all
of the relevant technology components required to
support the vision
5. Financial transparency Establishing the nancial
accountability and transparency necessary to
compete in todays consumer marketplace
6. Customer experience oversight and accountability
Dening the roles, responsibilities and metrics
for managing the organizations focus on the
customers experiences
As Novant executes its Patient Experience Roadmap,
it should continue to align the investment and returns
with the achievement of the Remarkable Patient
Experience.
Conclusion
The US health care system is becoming increasingly
competitive with patients behaving more like consumers
with regard to evaluating and selecting health care
options. Provider organizations should embrace innovative
strategies to deliver more effectively in this changing
environment. We believe a strategy of differentiated
Patient Experience provides an effective alternative to
the perilous zero-sum competition on the basis of cost.
Following a consumer-based approach to understanding
what patients want and developing the capabilities to
serve them as customers can lead to that differentiation.
Providers who execute this choice may well be on a path
toward sustainable and protable competitive advantage.
Novant is well along the path of executing their
multi-year Patient Experience Roadmap and is already
experiencing tremendous returns on investment
including:
A newly designed enterprise-wide Revenue Cycle
organization structure to support the future
state patient-focused operating model including
realignment of ~1,000 FTEs into new roles and
reporting relationships
Establishment of a Customer Service Contact Center
housing Scheduling, Pre-Visit Service Activities and
Customer Service
Consolidation of two Patient Financial Services
Business Ofces (hospital acute care and medical
group) to drive efciency and improve patient
service
Rationalization of HIM-related outsourced services
including Document Imaging, Coding and
Transcription
Implementation of a standardized and consolidated
Charge Description Master & new charge capture
processing enterprise-wide
Thus far, Novants remarkable patient experience
implementation for revenue cycle services is
generating ~$45 million in expense reduction and
~$60 million in incremental net revenue over the next
7 years. Truly remarkable.