Category Archives: Research

The Last Word on Improving Patient Satisfaction

You’ve improved your patient-care processes and outcomes but you’re still not happy with your patient satisfaction scores. And now, with CMS reimbursements increasingly tied to those scores, the pressure is rising to raise them.

Fortunately, the fields of psychology and behavioral economics may offer some easy-to-implement solutions to improve patient satisfaction scores both coming and going.

Start at the beginning

People’s memories are selective. They remember the beginnings and endings of things far more vividly and intensely than the middles.

The beginnings are particularly important, because they set up the patient’s expectations for everything that is to follow. It’s called “affect priming.”

If the beginning is stressful and unpleasant, the rest of the stay will have much repair work to do. Therefore, it is best to address patient satisfaction from the very beginning—the patient’s arrival at the hospital.

Address the parking situation: Worrying about finding a place to park is an issue that affects patients as well as their families. A free valet parking service can remove this worry and help create a caring first impression.

Careful maintenance of parking lots—to make them easily accessible, clean and safe— and liberal parking validation policies will also address this important opportunity to make a good first impression.

Greet everyone with a “Hello, can I help you?”  Even people who spend a lot of time visiting hospitals can have a hard time finding their way around. Making every visitor feel welcomed and taken care of must become everyone’s priority.

Specially trained volunteers and/or dedicated staff “Welcome Ambassadors” can make a real difference in visitors’ experience.

Add some branded swag to the intake and admission process: In addition to making people feel welcome, giving them some branded items at intake can help them feel a stronger and more positive connection to you.

The act of accepting the gift of a branded pen (and/or other items such as tote-bags, socks, tee-shirts, baseball hats etc.) creates a sense of endorsement and mutual regard on the part of a patient. (It also helps if the intake and admission process is streamlined and friendly, of course!)

Your Last Chance

Research by Daniel Kahnman and Donald Redelmeier1 has shown the power of happier endings. They found that adding a period of greater comfort to the end of a painful experience influenced subjects to remember their pain levels as less intense.

Even when they made the overall unpleasant experience longer, ending it more pleasantly made the whole experience seem more pleasant.

The takeaway from this research is simple:  Making the last few hours of a hospital stay more pleasant can change a patient’s lasting impression of the entire stay.

Here are a few last-day strategies that can pay big patient satisfaction dividends:

Special last day meals: Food is always one of the most memorable things about a hospital stay. Special meal treats on the last day before discharge , like an extra specially made desert, can help make patients feel as though they have been treated with special care.

Special last day farewells: It is easy for a patient to feel anonymous, especially in a large institution like a hospital. Post the discharge schedule at all unit stations, and make it a priority for all members of every shift – and every discipline, including support and non-clinical personnel – to review the list and stop in to offer some “goodbye” best wishes.

The 30 seconds it will take will yield long-lasting and highly positive memories for the patient—and for your staff members as well.

Special last day treats and gifts: The same discharge schedule can be used as a distribution schedule for more branded swag items like those mentioned above in association with intake.

Tote bags are especially handy at discharge, especially if they are needed to carry some parting gifts—all carrying your hospital’s logo imprint, of course. Specially branded cookies and cupcakes (decorated with your logo as icing) can also help patients leave with good memories of their stay.

Health care includes showing you care

We’ve all seen studies that show that patients who have good communications with their care-givers rate the quality of care they receive higher. That’s another area worth focusing on for raising patient satisfaction scores (and certainly worth a few future posts).

Good communication makes for good relationships, and both circle back to the “affect priming” mentioned at the beginning of this post. If you start by showing people you care about them, they will feel more cared about.

You show you care by being interested—genuinely interested—in how they feel and what they have to say. Which means that it’s not enough to start off that first contact with, “Hello, can I help you?”

You also need to listen to what comes next.

References1
Kahneman, Daniel; Frederickson, Barbara L.; Schreiber, Charles A. & Redelmeier, Donald A. (1993) When more pain is preferred to less: Adding a better end. Psychological Science, 4(6), pp. 401-405

Redelmeier, Donald A. & Kahneman, Daniel (1996) Patients’ memories of painful medical treatments: real-time and retrospective evaluations of two minimally invasive procedures. Pain, 66(1), pp. 3-8

Reducing Risky Behavior

Risk Communication Can Be Risky

Environmental Safety and Public Health Policy-Makers Often Make Matters Worse

Communication of science-based information to the general public…particularly health-related information…is a well-studied field.

This may be because it is so often done so poorly.

Many public behavior interventions, especially those based on intuition, “common sense,” political persuasion or religious belief, tend to focus on presenting a rational, logical argument for complying with a specific behavioral request.

Researcher Timothy D. Wilson cites “D.A.R.E.” and “Scared Straight” interventions…famous and widely adopted programs intended to reduce crime and drug use among young people…as examples of programs that “make perfect sense, but… are perfectly wrong, doing more harm than good. It is no exaggeration to say that commonsense interventions [such as these] have prolonged stress, raised the crime rate, increased drug use, made people unhappy, and even hastened their deaths.” (Source: Wilson, 2011, Redirect: The surprising new science of psychological change. New York: Little, Brown & Co.)

Unfortunately, this “boomerang effect” is too common in public policy communications. Public policy communicators would do well to read the government’s own manual on risk communication, which ought to be stapled to every keyboard in every PR department in every science, health and environmental organization in the English-speaking world.

Risk Is Attractive

Nike’s 5-minute animated World Cup commercial urges its audience to “Risk Everything,” basically because the safe route is boring. And clearly, there are a lot of risk-seekers out there.

While the animation and execution are exquisite, the storyline is predictable to the nth degree—but who cares? As an exercise in appealing to its targeted demographic: GOOOAAAAAALLLLLLLL!

The product shots are also very appealing. These are not the soccer cleats I wore in high school, and the shirts and shorts look as though world-cup-worthy pectorals, abs and glutes are included at no extra charge.

All this being said, the spot ought to be worrisome to conservatives, control freaks (including many sports coaches) and public health advocates. The reason it should be worrisome is not because of the spot’s likely influence on an easily-manipulated demographic—actually, soccer players are a rather stubborn lot. This spot is not going to change them in any way except maybe to increase their motivation to buy another pair of cleats.

No, the scarier scenario is that the spot is an accurate reflection of the risk-seeking ethos of an entire generation. In the spot’s storyline, risking everything is the only way to beat the practiced but predictable perfection of the clones (who could also be the minions of the Matrix, or the Man, or your parents).

But in real life, the associated behaviors are:

  • Going for the low-percentage spectacular dunk rather than the safe but boring lay-up
  • Riding the motorcycle without the helmet
  • Not buckling those seat belts
  • Not vaccinating your kids
  • Not stopping to unroll that Trojan
  • Not settling for the status quo.

Small wonder so many campaigns aiming to reduce risky behaviors actually serve to increase them. Maybe the control freaks and health communicators would do better if they positioned those undesired behaviors as something other than risky.

How about stupid? Or shameful? Or embarrassing?

As Nike is trying to tell them, risky is just too attractive.

We may not pay attention to the data in front of us, but they do

Data Driven Marketing

Data analysis
Analyze that data, or the data will analyze you

Are we making our choices and decisions based on our own objective, rational, informed analysis of each situation?

Most of the time, probably not.

Here are links to a couple of interesting Ad Age articles that show what some marketers are paying attention to.

A case for responsive web design
Moorhead article from Advertising Age
Moorhead article

In this article by Patrick Moorhead, shoppers who like to consult their smart phones about buying decisions are identified as more valuable than those who do their buying-decision-research at their desktops. BUT… not so much better as to suggest ignoring those desk-jockeys. Enter the responsive web site! (Like this one, for instance.)

All facts are not created equal
Lyons interview in Advertising Age
Lyons interview

Are you driven by data? Or are you driven crazy by data? In this Kate Kaye interview with historian-turned-data-cruncher Kevin Lyons, it becomes clear that the ability to gather and present data is not sufficient to provide real value. Not when dealing with an exponential expansion of available data. The trick is finding the relevant data amongst all the irrelevancies and not-quite-relevancies. (Sounds like there is a lot of opportunity to fudge those numbers. Look for an up-coming post on “Lies, Damn Lies & Statistics.”)

The Politics of HPV Vaccination Advocacy

Who would YOU listen to?

A study of the influence of spokesperson expertise

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NYSCA conference award for best graduate student paper
2013 NYSCA Conference “Top Paper” Award

My paper, “The politics of HPV vaccination advocacy: Effects of source expertise on the effectiveness of a pro-vaccine message,” was recently accepted for publication in the 71st Annual New York State Communication Association Conference Proceedings. The conference was held in Ellenville, NY, on October 18-20, 2013.

The paper received the conference’s award for Top Graduate Student Paper.

HPV (human papillomavirus) is a worldwide scourge that causes cervical cancer and thousands of deaths each year. Who do YOU think would be more influential in persuading people to support vaccination against HPV?

Most people would guess the authoritative-looking woman doctor on the left. After all, how much influence could a non-expert like the Middle School student on the right be expected to wield?

That was the focus of my study of spokesperson expertise.

Universal HPV vaccination would save more than 3,000 lives annually in the United States, and more than 350,000 worldwide. It makes sense. Its benefits seem almost inarguable. But there is a huge amount of opposition, largely distributed along political and ideological lines.

The intersection of health, science and politics

Mistrust and disbelief in evidence-based science and the recommendations of scientists are widespread and distributed along partisan lines. It is hard to prove any immediate life-and-death consequences to rejection of evolution or denial of the possibility of human agency in climate change. But with HPV and cervical cancer, the consequences are clear, present and immediate. We can document that partisan opposition to HPV vaccination is killing people right now.

The results of my study suggest that people who are inclined to oppose HPV vaccination are more likely to listen to and be influenced by pro-vaccination messages from an obviously non-expert spokesperson (in this study, an innocent-looking middle school student) than from an expert (in this study, an authoritative-looking woman doctor).

Three test groups: Expert, Non-Expert & Control

In my study, 474 adults were randomly divided into three groups. One group was instructed to read some basic, neutral information about the HPV virus and a pro-vaccination advocacy message attributed to the woman doctor.

A second group was instructed to read the same basic information about the HPV virus and the same pro-vaccination advocacy message, but for this group the message was attributed to the middle school student.

Expert vs Non-Expert
Expert vs Non-Expert

The third group (the control group) read the same basic information about the HPV virus, but received no advocacy message. Members of all three groups were also instructed to rate themselves politically as either Progressive, Centrist or Conservative.

After completing their reading assignments, the subjects were surveyed about their attitudes toward HPV vaccination.

The attitude-scores of the control group (the ones who read only basic information but received no advocacy message) showed how attitudes toward HPV vaccination are skewed along partisan political lines. The more conservative the individual, the more opposed to HPV vaccination that person was likely to be.

Subjects in the control group received no advocacy message
Subjects in the control group received no advocacy message

Displaying the results for all three groups side-by-side (see chart below), it is clear that Centrists and Conservatives—those more likely to be opposed to vaccination—are more positively influenced by the Non-Expert spokesperson than the Expert.

For both Centrists and Conservatives, attitudes among those who read the advocacy message from the Non-Expert were significantly more positive than among those who received no advocacy message. There was no such significant difference in attitudes of those who read the advocacy message attributed to the Expert.
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With Centrists, in fact, attitudes toward vaccination among those who received the advocacy message delivered by the Expert were virtually identical to those who received no advocacy message at all.

Among Progressives — who tend to favor HPV vaccination to begin with — attitudes toward HPV vaccination were more more positively influenced by the Expert than the Non-Expert.

Since virtually all pro-vaccination campaigns are spearheaded by people who favor vaccination, it seems likely that the tendency to rely on expert authorities as public advocates for vaccination may be the result of unexamined and untested assumptions that what influences Progressives will influence everyone.

Overall, these results suggest that HPV vaccination advocates would be more successful if they would enlist more non-expert spokespeople in their public information efforts. The results also suggest that information about scientific and politically charged subjects might receive greater attention from doubters if the information is delivered by spokespeople who are not immediately identifiable as expert advocates for the other side.

Someone seeing the serious-looking doctor knows another authoritative persuasive argument is coming and tunes out before any persuasion can happen. With the non-threatening middle school student, there is more chance that the persuasive message will be heard.

Some persuasion is more effective than none!

Reverse Psychology?

Yes, apparently you can actually get people to do something (or maybe NOT do something) by encouraging them to do the opposite.

There is a growing body of research that shows people can be discouraged from doing things they find pleasurable by paying them to do those things.

Theorists believe it demonstrates one of the major differences between intrinsic and extrinsic motivation.

When people do things because those actions give them pleasure or fulfillment, their motivations are intrinsic. Performing the actions becomes intertwined with their sense of identity: they do those things because of who they are.

When people do things because an outside force is compelling them to take those actions – by paying them, or forcing them or shaming them into it – their motivations are extrinsic.  There is not the same kind of connection with the sense of identity.

With extrinsic motivation, there is often an undercurrent of resentment – psychological reactance – and a lost sense of freedom that can sap the pleasure out of an action that may have once been performed for fun.  Extrinsic motivation tends to dampen and can even extinguish intrinsic motivation.

Putting this strategy into practice may be difficult, however. The chances of convincing any organization that must answer to public opinion to actually use this human tendency in an intentional way is pretty slim.

For instance, I don’t think we can convince the government that a good way to combat obesity would be to pay fat people to eat more.

But what about gun control?

Given the climate in the Republican-held House of Representatives, we are far more likely to pass a bill offering people financial incentives to own as many guns as possible than to pass a bill restricting gun rights in any way.

If we could get the government (i.e., the hated government, from which no good can ever come) to pay people to own guns, maybe this would work better to discourage gun ownership than trying to legislatively take away people’s right to bear arms.

By the way, on the subject of gun control, people on both sides of the debate could gain additional perspective on the matter by reading the classic science fiction novella, “The Weapon Shops of Isher,” by A.E. van Vogt.

Calling all racists

So you think we live an a Post-Racist Society? Well, what was your gut reaction to the title of this post?

I’m a fan of Cognitive Friction. It happens when you take two sets of facts or ideas or ways of looking at the world and you rub them together. For instance, many people think we live in a post-racist society, but the act of cognitive friction can reveal something very different.

unconscious leanings and biases
We are often unconscious of our leanings and biases

The evidence of Harvard’s Project Implicit shows that the overwhelming majority of people in the United States – whites and people of color, young and old, rich and poor – harbor a deep-seated bias against darker skinned people. They persistently and unconsciously associate lighter skin on the positive side and darker skin on the negative side of the continuum on all the following sets of characteristics:

Smart vs Stupid

Good vs Bad

Safe vs Risky

Peaceful vs Risky

Lawful vs Unlawful

Beautiful vs Ugly

Likable vs Unlikable

Positive vs Negative

Self examination can lead to self awareness
How well do you know your own biases?

Okay, you might say, that may be true but it is just an unconscious bias that we all have learned to overcome because we do not agree with racism, we do not approve of racism, and we do not believe we are racists. Our conscious decisions about how we choose to act serve to mitigate and eliminate the effects of this racist bias. And it is, after all, our conscious choices that define us.

But if we rub the evidence of Project Implicit up against the evidence of a growing number of studies of elaboration likelihood (i.e., whether people are likely to engage in rational, conscious thought about something), we might start to worry.

These studies of conscious vs unconscious processing demonstrate that perhaps 95 percent of our actions are performed unconsciously, without intentional rational deliberation. Like the way we drive our cars, we mostly operate on autopilot. We may think we are thinking about something, but usually we are paying as little attention as possible while actually thinking about something else.

When these sets of findings are considered separately, there is little cause for alarm about the human condition, or about the persistence and pervasiveness of racism in the United States. But taken together, they suggest that even among people who abhor the idea of racism, 95 percent of their decisions and actions are undertaken under the unmitigated influence of a broad and deep-seated racist bias. Yes, racism is alive and well and we are all contributing to its expression.

Want to check your own degree of racism? Go to https://implicit.harvard.edu/implicit/demo/ and poke around.

Train Your Auto Pilot

My son taught himself to play the impossibly fast passages in Mozart’s Clarinet Quintet by breaking the hard parts down into small groups of three or four notes, and practicing the small groups until they were mastered—until they could be played without having to think of and search for each individual note.

Then he joined the groups of notes together, slowly, until they could be played more quickly. Eventually he joined all the groups together into an astonishing performance.

He learned this technique of training his Auto Pilot with the help of a succession of inspired music teachers. Some of them called it, “Building muscle memory.”

Actually, I have heard this “muscle memory” explanation a lot, and it bothers me. Last I heard, muscles don’t have memories, but they are controlled by something that does—the brain.

I think there may be an unconscious urge to shy away from thinking about the things the brain may be doing that we are not aware of. (Maybe the Auto Pilot wants to stay hidden?) I hear other aspects of Auto Pilot behavior chalked up to simply being habits, as if a habit is not something our brain learns to do while we are not consciously trying to learn anything.

The part and/or function of the brain I call the Auto Pilot (and that T.D. Wilson, in Strangers to Ourselves, calls “the adaptive unconscious”) is observing and learning constantly, and using what it learns to predict what will happen next so that it can direct our bodies to take appropriate actions. These actions are not limited to simple sequences of muscle movements, but can include complex behavior patterns.

So, for instance, when we are crossing the street, our Auto Pilot notices how close we are to the curb so we don’t trip; notices the puddle so we avoid it; notices the car that is about to hit the puddle and splash cold, muddy water near us—and before the splash ever happens, we are already back-pedaling to stay dry.

The Auto Pilot doesn’t have eyes in the back of our head, however, so when the bicyclist who is coming up behind us shouts angrily at us for backing up unexpectedly into his path, it registers surprise – and so do we, swiveling our heads to see where the biker is and leaping quickly out of his path, and maybe flipping him the bird while we’re at it.

The Auto Pilot is always learning, and always making predictions. If reality falls in line with our Auto Pilot expectations, we can go humming along merrily through the day, not having our attention directed to unexpected bikers and other things that may surprise us. And this, I believe, is our usual state of affairs: busy paying attention to something else—a phone conversation, a memory, a worry—while cruising on Auto Pilot.

The default control of our Auto Pilot and this learning-predicting-surprising sequence has tremendous implications for marketers, especially advertisers and brand managers. Here are three quick take-aways for them:

(1) Advertisers who want to get their advertising noticed would do well to find ways to surprise the Auto Pilot.

(2) To build brand equity, a brand manager would do well to try to teach the Auto Pilot to predict positive experiences in connection with the brand.

(3) If you have a dominant position in the marketplace, avoid surprises and don’t defy any expectations. Just show a smiling kid eating your Happy Meal and make sure the Drive-Thru is open.

Writing to Persuade & Get Paid

Some of what I learned in teaching persuasive writing

1.  Emphasize the connection between audience interests and client objectives
2.  Everybody needs to get better at punctuation and proofreading

I just finished teaching a new course in persuasive writing at the Sage College of Albany called “Writing to Persuade and Get Paid.”

My plan was to give the class members an opportunity to explore and practice the different writing styles, approaches and mindsets needed to succeed in advertising, public relations, marketing and website applications.

One size does not fit all when you are writing to persuade. Approaches that work in advertising will not work in public relations or as website content.  Approaches geared for mass audiences such as those used in advertising, public relations and websites are generally not effective for the narrow-focus writing required for marketing plans and business proposals.  Each genre requires good, competent writing, but each has specific requirements that are different from the others.

Advertising has to be intrusive and attention-getting because it needs to grab your audiences’ attention away from all the other persuasive messages that are competing for their attention. It also has to overcome their reluctance to be the target of unwanted advertising.

Writing for public relations may not call for as much verbal flamboyance as advertising, but it requires an understanding of newsworthiness and relationship building.

Marketing plans and business proposals need to provide a compelling, credible story that shows (not just explains) why your product, service, business or idea is going to provide tangible and emotionally satisfying rewards if your target audience takes the action you are advocating.

Website content is different from the three types of writing described above in that it is usually something your target audience is actively searching for, so instead of needing to convince reluctant audiences to pay attention, your job is to reward time-pressured and frustrated searchers for having found what they have been looking for.

In each case, you need to understand your audiences’ objectives as well as your own. And you achieve your greatest success when you understand that fulfilling your audiences’ objectives is the most certain route to achieving your own.

The first semester of a new course is always a learning process for the teacher as well as the students.  This was intended to be a course for good writers and those who wanted to become better writers.  It turned out that although the class attracted students who definitely wanted to become better writers, we needed to spend a lot of effort working our way toward “good.”

While we were able to cover the basic writing formats and strategies for the different writing genres, the most valuable lessons involved studying up on punctuation and proofreading rather than persuasion.

Since we are being alliterative, it might be apropos to call it a prioritization process. Proper punctuation and proofreading are prerequisites for persuasion.