If you employ a few hundred nurses, how exactly would you evaluate how well they show empathy?
You can't rely on asking the customer. When they're upset (they often are in these calls), they'll lean towards the negative regardless.
I don't know how well these AIs evaluate, but if they're even a little bit good, it makes sense to use it to screen for outliers, then have a human listen to those outliers and judge.
"You can't ask people because the experience is so universally terrible they'll just tell you it's terrible" isn't really an argument against surveys, it just means you need more specific questions they'll be fired up to answer
Let me suggest the following: Ask the nurses if they want the customer to rate them.
A significant fraction of the calls they answer are patients shouting at them because of:
- Long wait times
- They don't like their doctor
- They don't like the advice they're given (sorry, but we're not going to book you as a high priority appointment if all you can tell me is you have a headache. Sorry, we're not going to prescribe a narcotic for a scraped knee.)
- Several reasons that have nothing to do with the nurse, but the customer will still blame the nurse.
Most of the folks here on HN are dealing with customer feedback in systems automation in one form or another - it's pretty unavoidable in this age of LLM trendiness. The customers of healthcare (in both private and publicly funded systems) are the patients. So while the term might not be super natural it's an understandable one to use.
Patients are not customers, or at least I don’t want to live in a world where patients are considered customers. Customers and vendors are usually more of a symmetric relationship: price transparency, alternatives, lack of urgency. These are all characteristics of transactions that healthcare often lacks.
But they don't want to, because figuring that out is your job as a supervisor.
If you outsource that work to customers/patients, you'll end up with the car dealership model, where the sales rep begs you to give a 10 on every single question including on the interior design so they don't get fired.
That's the part most of this discussion misses. Supervisors exist for a reason. Congrats on your flat org structure, you fucked up an important feedback channel.
> where the sales rep begs you to give a 10 on every single question including on the interior design so they don't get fired.
Oh yes, and the nurses did employ strategies like that pre-LLM (don't know if they still do). They had to be very strategic about it (you can't just say "Rate me a 10.")
This problem with workplace AI interfering with nurses ability to manage healthcare obligations for their clients is not confined to Kaiser. UHC has also introduced the AI surveillance tools and are using it to do similar things.
> that might appear to be incentive to improve quality
Their goal isn't to provide high quality care. Their goal is to increase profits. It's not hard to imagine how improved quality would lead them to spend more money. (faster diagnoses of serious illnesses and recommending expensive care)
Psychopaths don't care about other peoples pain. They only care about their own ego, power, and money. They do well in corporate cultures that reward parasitic relationships with customers. =3
What these complaints always boil down to is autonomy and control.
The more centralized an organization, the more it relies on metrics to understand and exert control over its employees and customers.
People started hating tech right around the time metrics became popular. I don't think it's a coincidence. AI just accelerates the trend.
The problem is the misidentification of AI as the issue. As long as we don't understand the real issue, we won't solve it. AI is just a tool. It's being used in a way that denies human agency.
Our cultural values need to shift away from safetism that demands centralization. And shift toward valuing human agency. That starts with talking about the core issue.
Everyone pushing tools/AI during initial development/investment and building its demand in the cultural discourse always highlights its ability for good.
Now, like many tools, the majority of those selling AI to make money off of large enterprise sell its ability to increase productivity, efficiency, compliance. Either to make money or to minimise risk. And so like you say, they just become tools to make these metrics move or report them at higher granularity. And often there is either a lack of imagination or a willful ignorance of the perverse outcomes with relationship to humans because they are in service of the organisation not it's employees.
I'd like to think it's not meant to make life better for a regular nurse, but rather to weed out the abusive ones? At least that's how I see it from my flawed, post-communist country perspective.
> "Nurses fear that having long calls can lead to bad performance reviews"
> A company spokesperson said, "Kaiser Permanente does not use Average Handle Time to assess agent performance"
So uh, average time wasn't raised as a concern, calls beyond a certain threshold was. I wish this semantic discrepancy was better highlighted in the article.
They claim they do not use average handle time, but it is very common to get called into meetings to discuss why they spent a lot of time on some calls. The nurses get defensive (by definition - they have to justify the time used - it is a defense).
They also do get called into meetings if their average handle time is large.
It may still be true they don't use it for evaluating performance, but they absolutely do utilize it to "coach" the nurses.
It might not be a written metric, but do you actually believe that someone isn't being evaluated partially based on how many times they've had to talk to them about issues?
I highly doubt it. If this is the reason your manager knows who you are, you are absolutely going to be judged on it. It doesn't really matter what the policy says.
And the nurses absolutely feel like they are being punished for it. Just like having to consistently remind HR that your "absence problem" is due to covered FMLA leave - they know who you are because they've had to talk to you about absenteeism. In a call center of 500 people, it isn't likely they remember that you had issues because of their faulty systems.
> but do you actually believe that someone isn't being evaluated partially based on how many times they've had to talk to them about issues?
This is true for any job. I was unfairly fired from a job because somehow the manager got a perception of me being incompetent, because he often talked to me about problems in my work - most of those conversations ended with him saying "Oh, now I see why you did it that way."
Yeah, I didn't even want to lean out that far but I'm sure average handle time is incorporated in some manner.
But, just purely semantically, the statement Kaiser gave in response was worded in a precise smug corporate America style to dodge the main concern raised. I think it's important to call out weasel words.
> the statement Kaiser gave in response was worded in a precise smug corporate America style to dodge the main concern raised
I know nurses. And I know their unions. Kaiser can be extremely clear and tell the truth, and they'll still say "We don't believe you!" without any evidence other than being called in to talk about it.
I'm not anti-unions - I've benefited from them. But it's well known that distrust goes up when you have (or need) unions. It typically degenerates from "We" to "Us vs them".
Let me ask you this: Are you saying they shouldn't monitor the time at all?
Again: A tidbit of inside information: A number of Kaiser patients get such long wait times that they're issue isn't addressed when they try to call (i.e. they are told they'll be called back, and they're called back some other day). I don't know the percentage - likely small - but from a healthcare standpoint, it's unacceptable.
Another bit of information (likely not inside): Kaiser has a serious budget problem. They already pay amongst the top salaries for nurses, and they can't simply solve the problem by hiring more.
There's definitely a lot of room for weasel-wording there, where the metric really being used isn't the mathematical mean, but punishes people just the same.
I would love to learn the cost of the AI versus how many new workers they could afford to hire and get more calls done. But I assume the end goal will be full replacement of human workers once the AI has had enough time to learn the job.
With all of that in mind I have to wonder whether there is overlap between these response groups and if so, how much. Could be zero to 100% without more information.
The care quality of all major healthcare providers in the US is some pretty available data, and I've never heard anyone of being suspicious of Kaiser, of all companies. They're specifically known for having really good outcomes. It's like asking for a source that McDonald's sells the most burgers in America. It might not be true - maybe technically it's someone selling sliders or whatever, but it's so close it's probably not worth arguing over anyways.
> Nurses are instructed to stick to a script on phone calls and give no more than two to three pieces of advice, Capulong and other nurses said, which means they may sometimes need to decide whether to withhold advice or face a performance evaluation hearing.
> Another nurse speaking on condition of anonymity said “AI did not understand our job and would grade us wrong all the time.”
In theory AI could usher in the first time in history where one can escape from this trap - because qualitative judgments can be made at scale, from an unbiased and universal baseline. In this situation, for instance, rather than collapsing call transcripts and reports into metrics, it could evaluate whether red flags are encountered in the context of a call, and allow for qualitative guidance on improvement, across a comparative corpus of situations that are themselves chosen qualitatively.
But very few managers are empowered to take this kind of approach; they're evaluated by their ability to report quantitative metrics, and thus they must implement regimes of quantitative metrics. And leadership instructs them to use AI to build that regime more quickly.
If you want to see an "AI native" organization, it's one where leadership actively fights this tendency, and sees managers as product designers who make the end-user experience a beloved and empathy-driven one, as opposed to a gear that turns accountability into a single number on a screen.
While I'm sympathetic to the frictions of newly introduced AI and the fact that AI in healthcare, especially calls, can seem very uncaring, between the lines the article reads a bit like the typical union complaining about modern tech that reshapes their work, given the multiple mentions of protests, nurses union, etc.
Given how healthcare is one of these sectors that seems to relentlessly resist efficiency increases and is the prime example of Baumol's cost disease, I think any developed country with a costly healthcare system needs to do these AI experiments. The current versions will be shit, but the only way out is through if you still want to provide affordable care.
I honestly have no doubt that AI going forward will be able to do a good job at triaging via calls and also being empathetic about it. But of course it needs careful experimentation.
If you think using a machine to evaluate how well a human is showing empathy is a good idea, you probably shouldn't have any position of power.
Power is based on wealth extraction, not merit.
Increasingly true in Trump’s America.
isn't that exactly what a class terrified of the guillotine would want underclasses to believe?
In the future that class will control the guillotines in the form of Boston Dynamics guard dogs.
Êtes-vous français?
If you employ a few hundred nurses, how exactly would you evaluate how well they show empathy?
You can't rely on asking the customer. When they're upset (they often are in these calls), they'll lean towards the negative regardless.
I don't know how well these AIs evaluate, but if they're even a little bit good, it makes sense to use it to screen for outliers, then have a human listen to those outliers and judge.
> how exactly would you evaluate how well they show empathy?
How would you want yours rated? By someone you have communicated with, or some data centre somewhere?
By a knowledgeable/skilled person who listens to the call. (Which the AI solution provides).
I suppose you could do that with the survey as well. It'd be an interesting study to see which is more reliable.
"You can't ask people because the experience is so universally terrible they'll just tell you it's terrible" isn't really an argument against surveys, it just means you need more specific questions they'll be fired up to answer
Let me suggest the following: Ask the nurses if they want the customer to rate them.
A significant fraction of the calls they answer are patients shouting at them because of:
- Long wait times
- They don't like their doctor
- They don't like the advice they're given (sorry, but we're not going to book you as a high priority appointment if all you can tell me is you have a headache. Sorry, we're not going to prescribe a narcotic for a scraped knee.)
- Several reasons that have nothing to do with the nurse, but the customer will still blame the nurse.
So.. good feedback?
Actually, you can rely on the customers. They're the only ones that can tell you.
> you can rely on the customers.
Patient or customer? I even struggle with that, but I guess that’s what people are in a privatised healthcare system.
Most of the folks here on HN are dealing with customer feedback in systems automation in one form or another - it's pretty unavoidable in this age of LLM trendiness. The customers of healthcare (in both private and publicly funded systems) are the patients. So while the term might not be super natural it's an understandable one to use.
Patients are not customers, or at least I don’t want to live in a world where patients are considered customers. Customers and vendors are usually more of a symmetric relationship: price transparency, alternatives, lack of urgency. These are all characteristics of transactions that healthcare often lacks.
But they don't want to, because figuring that out is your job as a supervisor.
If you outsource that work to customers/patients, you'll end up with the car dealership model, where the sales rep begs you to give a 10 on every single question including on the interior design so they don't get fired.
That's the part most of this discussion misses. Supervisors exist for a reason. Congrats on your flat org structure, you fucked up an important feedback channel.
> where the sales rep begs you to give a 10 on every single question including on the interior design so they don't get fired.
Oh yes, and the nurses did employ strategies like that pre-LLM (don't know if they still do). They had to be very strategic about it (you can't just say "Rate me a 10.")
Not asking the customer because you're afraid they'll tell you they're upset is a good indicator that you should do it more, and fix the issues.
You can ask the customer enough times that unreasonable customers or surveys are averaged out.
A good question might be "why are you upset?"
This problem with workplace AI interfering with nurses ability to manage healthcare obligations for their clients is not confined to Kaiser. UHC has also introduced the AI surveillance tools and are using it to do similar things.
Isn't that the insurance company whose CEO was murdered because of the terrible quality of care they delivered?
Yes it is. Somehow that might appear to be incentive to improve quality of care but maybe their corporate culture is a bad fit for quality.
> that might appear to be incentive to improve quality
Their goal isn't to provide high quality care. Their goal is to increase profits. It's not hard to imagine how improved quality would lead them to spend more money. (faster diagnoses of serious illnesses and recommending expensive care)
Psychopaths don't care about other peoples pain. They only care about their own ego, power, and money. They do well in corporate cultures that reward parasitic relationships with customers. =3
It is true that Despotism structures major failing was the scaling cost of surveillance necessitated to differentiate fact from fictional narratives.
Truth is most nurses care for people having the worst day of their lives. =3
Thinks that are not allowed in the EU thanks to the AI Act.
What these complaints always boil down to is autonomy and control. The more centralized an organization, the more it relies on metrics to understand and exert control over its employees and customers.
People started hating tech right around the time metrics became popular. I don't think it's a coincidence. AI just accelerates the trend.
The problem is the misidentification of AI as the issue. As long as we don't understand the real issue, we won't solve it. AI is just a tool. It's being used in a way that denies human agency.
Our cultural values need to shift away from safetism that demands centralization. And shift toward valuing human agency. That starts with talking about the core issue.
Everyone pushing tools/AI during initial development/investment and building its demand in the cultural discourse always highlights its ability for good.
Now, like many tools, the majority of those selling AI to make money off of large enterprise sell its ability to increase productivity, efficiency, compliance. Either to make money or to minimise risk. And so like you say, they just become tools to make these metrics move or report them at higher granularity. And often there is either a lack of imagination or a willful ignorance of the perverse outcomes with relationship to humans because they are in service of the organisation not it's employees.
> AI is just a tool
"To the man with a hammer, everything looks like a nail." [1] There is no such thing as "just" a tool.
----
[1] - https://en.wikipedia.org/wiki/Law_of_the_instrument
I'd like to think it's not meant to make life better for a regular nurse, but rather to weed out the abusive ones? At least that's how I see it from my flawed, post-communist country perspective.
> "Nurses fear that having long calls can lead to bad performance reviews"
> A company spokesperson said, "Kaiser Permanente does not use Average Handle Time to assess agent performance"
So uh, average time wasn't raised as a concern, calls beyond a certain threshold was. I wish this semantic discrepancy was better highlighted in the article.
I have some inside information (but not much!)
They claim they do not use average handle time, but it is very common to get called into meetings to discuss why they spent a lot of time on some calls. The nurses get defensive (by definition - they have to justify the time used - it is a defense).
They also do get called into meetings if their average handle time is large.
It may still be true they don't use it for evaluating performance, but they absolutely do utilize it to "coach" the nurses.
It might not be a written metric, but do you actually believe that someone isn't being evaluated partially based on how many times they've had to talk to them about issues?
I highly doubt it. If this is the reason your manager knows who you are, you are absolutely going to be judged on it. It doesn't really matter what the policy says.
And the nurses absolutely feel like they are being punished for it. Just like having to consistently remind HR that your "absence problem" is due to covered FMLA leave - they know who you are because they've had to talk to you about absenteeism. In a call center of 500 people, it isn't likely they remember that you had issues because of their faulty systems.
> but do you actually believe that someone isn't being evaluated partially based on how many times they've had to talk to them about issues?
This is true for any job. I was unfairly fired from a job because somehow the manager got a perception of me being incompetent, because he often talked to me about problems in my work - most of those conversations ended with him saying "Oh, now I see why you did it that way."
Yeah, I didn't even want to lean out that far but I'm sure average handle time is incorporated in some manner.
But, just purely semantically, the statement Kaiser gave in response was worded in a precise smug corporate America style to dodge the main concern raised. I think it's important to call out weasel words.
> the statement Kaiser gave in response was worded in a precise smug corporate America style to dodge the main concern raised
I know nurses. And I know their unions. Kaiser can be extremely clear and tell the truth, and they'll still say "We don't believe you!" without any evidence other than being called in to talk about it.
I'm not anti-unions - I've benefited from them. But it's well known that distrust goes up when you have (or need) unions. It typically degenerates from "We" to "Us vs them".
Let me ask you this: Are you saying they shouldn't monitor the time at all?
Again: A tidbit of inside information: A number of Kaiser patients get such long wait times that they're issue isn't addressed when they try to call (i.e. they are told they'll be called back, and they're called back some other day). I don't know the percentage - likely small - but from a healthcare standpoint, it's unacceptable.
Another bit of information (likely not inside): Kaiser has a serious budget problem. They already pay amongst the top salaries for nurses, and they can't simply solve the problem by hiring more.
So: How would you solve it?
Are these nurses currently represented by a union?
There's definitely a lot of room for weasel-wording there, where the metric really being used isn't the mathematical mean, but punishes people just the same.
balls, that's the metric line managers use to figure out who's out of whack
Maybe healthcare shouldn’t be primarily for profit?
Well, I suppose you can rest easy on that count. Kaiser is principally a non-profit.
> principally a non-profit.
I hate to break it to you, but "non-profit" doesn't mean what you literally think it means.
https://en.wikipedia.org/wiki/Kaiser_Permanente
Also, KPMGs are indeed "for-profit" while Kaiser Permanente as a whole is constituted as a "consortium" of both types.
Do you suppose thats why they wrote "principally"?
But what about competition!?!?
I would love to learn the cost of the AI versus how many new workers they could afford to hire and get more calls done. But I assume the end goal will be full replacement of human workers once the AI has had enough time to learn the job.
The AI is a lot cheaper. Kaiser nurses are amongst the highest paid in the nation.
Now let's talk about how AI could replace Kaiser middle management and streamline bureaucracy to preserve more budget for doctors and nurses...
How dare the people who take of the sick and dying be paid well. Unacceptable waste that must be optimized!
We're liberating them from work so they can focus on what matters
Subsidized Gen AI maybe.
Also, California has a high cost of living.
Obligatory dystopia reminder. It doesn't have to be this way https://marshallbrain.com/manna1
But we're all in on making it that way!
There's a reason that among Americans, telekinesis and creationism are more mainstream positions than sloptimism.
About 14% of Americans think AI is moving us towards a better world. About 17% are creationists. About 26% believe in Telekinesis.
With all of that in mind I have to wonder whether there is overlap between these response groups and if so, how much. Could be zero to 100% without more information.
Kaiser has some of the best healthcare outcomes in the country/world due to their protocols and how good they are in ensuring adherence to them.
It’s going to be very improbable that these statements are true.
Compared to what?
> Kaiser has some of the best healthcare outcomes in the country/world due to their protocols and how good they are in ensuring adherence to them.
Where and how is that determined? I.e., any references to back that up?
And you can't in one breath say they have the best healthcare but then say their employees' reports of their experience are unreliable.
Not sure if you’re serious but just search the name Kaiser in any research search engine.
https://pmc.ncbi.nlm.nih.gov/articles/PMC8032167/
Their secret sauce is their ability to standardize protocols throughout their entire organization.
That’s the measure for one pathology, but in terms of a provider comparison, what’s the measure? It isn’t dollars versus life span or morbidity.
Study is from 2000-2013, their care has deteriorated significantly since then. I know because I've been a patient the whole time.
The care quality of all major healthcare providers in the US is some pretty available data, and I've never heard anyone of being suspicious of Kaiser, of all companies. They're specifically known for having really good outcomes. It's like asking for a source that McDonald's sells the most burgers in America. It might not be true - maybe technically it's someone selling sliders or whatever, but it's so close it's probably not worth arguing over anyways.
> Nurses are instructed to stick to a script on phone calls and give no more than two to three pieces of advice, Capulong and other nurses said, which means they may sometimes need to decide whether to withhold advice or face a performance evaluation hearing.
> Another nurse speaking on condition of anonymity said “AI did not understand our job and would grade us wrong all the time.”
It's always worth remembering Goodhart's law https://en.wikipedia.org/wiki/Goodhart%27s_law - "When a measure becomes a target, it ceases to be a good measure."
In theory AI could usher in the first time in history where one can escape from this trap - because qualitative judgments can be made at scale, from an unbiased and universal baseline. In this situation, for instance, rather than collapsing call transcripts and reports into metrics, it could evaluate whether red flags are encountered in the context of a call, and allow for qualitative guidance on improvement, across a comparative corpus of situations that are themselves chosen qualitatively.
But very few managers are empowered to take this kind of approach; they're evaluated by their ability to report quantitative metrics, and thus they must implement regimes of quantitative metrics. And leadership instructs them to use AI to build that regime more quickly.
If you want to see an "AI native" organization, it's one where leadership actively fights this tendency, and sees managers as product designers who make the end-user experience a beloved and empathy-driven one, as opposed to a gear that turns accountability into a single number on a screen.
> Nurses are instructed to stick to a script on phone calls and give no more than two to three pieces of advice
So stupid. If you had ever made a phone call to a patient, or their family member, you’d soon realise how bad this is.
You need to talk to the patient and something a family member too. Be too hasty and you cause more harm than good.
Unpopular opinion: People want to be lazy and hate things that force them to work harder.
They will vocally rationalize it.
I did it. "I'm more productive work from home." But then I do dishes, take an hour break, paid.
Foucault says that when people are observing them, power is placed over them.
If you are a worker you should hate this.
If you are a customer or owner, you should like this.
But I certainly won't be automatically believing people under surveillance who make claims it makes their quality worse.
clearly you have never been a floor nurse at a hospital...
While I'm sympathetic to the frictions of newly introduced AI and the fact that AI in healthcare, especially calls, can seem very uncaring, between the lines the article reads a bit like the typical union complaining about modern tech that reshapes their work, given the multiple mentions of protests, nurses union, etc.
Given how healthcare is one of these sectors that seems to relentlessly resist efficiency increases and is the prime example of Baumol's cost disease, I think any developed country with a costly healthcare system needs to do these AI experiments. The current versions will be shit, but the only way out is through if you still want to provide affordable care.
I honestly have no doubt that AI going forward will be able to do a good job at triaging via calls and also being empathetic about it. But of course it needs careful experimentation.