What is PX?

Beryl Institute has, what I would consider, the best (certainly the pithiest) definition of Patient Experience—the sum of all interactions, shaped by an organization’s culture, that influence patient perceptions across the continuum of care. 

OK, there you have it, shortest blog post ever. 

Actually, when I ask ‘what is patient experience,’ I really want to discuss a rather nettlesome thicket that has evolved over time about how we label what we do.  It may have started as an effort to throw our arms around the work, but has, of late, also has had us play linguistic games that at-best get us paralyzed with navel-gazing and at-worst have us eating our own young.  And none of it gets us closer to the important work at hand. 

This essay is primarily linked to a conversation I had awhile back when I introduced myself as the Vice President of Patient Experience and Consumerism.  The response I received was that this title was too limiting, even prosaic, relative to the real work we needed to do.  This introduced me to a certain conversational cul-de-sac about what we call what we do and how that name becomes more important than the actual work we do.  I think it is valuable to have a definition that we can plant as a flag, so we can determine whether we are getting closer or further away from our goal.  But I also think that this effort to refine or redefine what we do becomes more of a stick that we use to beat others with than a flagpole that we can use to motivate and guide. 

Back when I first got into this space and dinosaurs ruled the earth, we called what we did Patient Satisfaction.  But it was determined that this was too broad.  After all, we were not looking to simply satisfy a patient, but to provide them with something that would connect them to their care, want to come back, and say nice things about us in the community.  So Patient Experience supplanted Patient Satisfaction as our phrase of choice. 

But then, some thought that this term made patients appear too passive—they received an experience.  We wanted patients to be more active in their care, as in, ask for help when they are in our active care and follow their discharge instructions when they are out of our field of vision.  So, begat the age of Patient Engagement, at least for some.

Still, this too did not really capture what we were about, since this work should not be in its own silo.  It should be engrained into all things we do.  So, when patients are in our care, we can call it Patient-Centered Care and then they are out in the broader world, we might call it Patient Consumerism.  They are not just active participants, but the focus of all we do. 

And now, I am hearing Person-Centered Care, Human Understanding, or Uniqueness.  This seems to take the conversation to a much more granular level.  We must identify that the patient is the center of the care, but that each patient requires a different level of connection to that care.  We cannot provide one-size-fits-all experiences or engagement. 

This, perhaps counterintuitively, led us to bring others to the table, as family support and community resources certainly colored how that care would be realized by any individual patient.  This further needed us to include the care team, as their needs, engagement, workload, and specialization would also provide context for this care.  Beryl has a definition of Human Experience which folds into this work, the perspective of family, healthcare workers, and the communities that these health systems serve.

Now, I do think that this transition is valuable in some ways.  Moving from simple satisfaction to building a connection to promoting better compliance and loyalty, to understanding that families, care teams, and communities deserve a seat at the table is useful.  We could all sit around with a coffee or a beer and hold forth on which of these is the most accurate, useful or respectful term. 

My concern, though, is that when I hear this discussion of terminology, it seems that it falls into one of two broad categories:

Navel gazing: This is the process of trying to define what we do accurately rather than actually doing the work.  Too often I have heard of work getting delayed or sidetracked because there is an argument over how we self-identify the work.  This is not to say that we don’t need boundaries or conversations about what is in-scope or out-of-scope for a committee, an action or a focus.  But these conversations aren’t really discussing the role of patient advocacy, patient access, or civil rights or whether risk, quality or marketing should be present.  They just swirl on what something is named.

Gatekeeping: Increasingly, some of this linguistic battle is really over showing who has the truest credentials, who is the most ardent fan, who is the OG.  Embracing one over the other tags someone as passé or a hipster.  When this conversation feels like a conversation over who is the ‘true fan’ of a band, or whether that band is good or so-last-year, it feels more like someone is defining THEMSELVES and not the work they seek to do. 

For the record, I think:

• ‘engagement’ implies a more active relationship with the healthcare provided
• ‘experience’ implies a more immediate bedside connection
• I think a definition that acknowledges the role of the care team, family, community, and social determinants of health (SDoH) of a patient is valuable. 
• I think ‘consumerism’ is also important, but is dangerously close to being co-opted by the marketing folks and in saying that I just caused some PX folks to roll their eyes at that truth. 

BUT my concern with expanding the circle that the definition seeks to encapsulate threatens to marginalize the patient.  By including the care team, family members, community leaders, etc., we have by-definition watered-down the importance of the patient, which is why we started this work to begin with. 

Forgive me, but I often return to the realm of statistics to help me sort out things, including definitions.  When inferring truths about a population from samples, you need to make sure you be wary of both

• Type I Error which is saying something is true when it is really false
• Type II Error which is saying something is false when it is really true

Now statisticians are trained to avoid both errors, but the reality is that they are related and the best you can do is balance the two since fighting aggressively to eliminate one with simply exacerbate the other.  If I set my standards for accuracy so stringently that only the things that are absolutely and epistemically TRUE will be labeled as true in my analysis, I will certainly miss things that are true but have not reached my high level of certainty.  In other words, by eliminating Type I Error, I have increased Type II Error.  On the other hand, if I set my threshold low, so I will never miss a single truth, I have cast my net so broadly that I am certain to label some things as true, which are not really true.  So, minimizing my Type II Error means accepting the presence of Type I Error.

[My apologies for springing some math on you without warning.  At 214 words, I hope you didn’t drift off.  Also, apologies to my statistician friends who might want to pick nits over the complete accuracy of what I said above.  I generally strive for truthiness over rigor, or as my father will certainly tell you, I have never let the facts get in the way of a good story.]

How is this related to the definition of PX?  Because if what we want to do is to maximize our patient’s satisfaction/experience/engagement in-the-moment, we are certainly going to miss key elements associated with the care team, the patient’s family or the community that the patient resides in.  But, if we focus on maximizing our appreciation for all external variables, we may miss out on how to build a positive experience with this one patient in this one care experience.  

From a work perspective, defined too narrowly, PX becomes simply responding to and managing patient complaints and grievances.  This is important work to be sure, but it is very reactive, it doesn’t consider tomorrow’s patient, and often it is not nourishing to the soul.  While I have met a few people who are somehow inspired by managing an endless sea of lost dentures, misplaced rings and care concerns (both honest and frivolous), it is work that tends to burn people out. 

Defined too broadly, and PX gets involved in issues of civil rights, social determinants of health, marketing, clinical quality, risk, HR, the patient portal, and even finances.  In essence, anything that gets defined as “patient-facing” gets lumped into PX.  This may seem legitimate and valuable, but most organizations are simply not staffed with PX teams who can cover all of that territory and effectively deliver on the PX promise.  So, nothing gets done effectively.  It leads to PX being the junk drawer of any healthcare organization.

So, Joe, you might be saying, didn’t you just spend a ton of time telling us not to spend a ton of time on this?  OK, maybe.  But I prefer to say that I spent time wading in the mud, so you don’t have to.

As you look around at all the gaps surrounding the patient experience in your organization, I hope that you are excited and invigorated and not overwhelmed.  But regardless of where you are, remember that if EVERYTHING is PX, then NOTHING is PX.  Please pick your tasks, your teams, accordingly.  Your patients will thank you, which is what it is all about.