One issue that anyone tasked with overseeing patient experience has wrestled with is how to motivate staff to use the PX training they have received. After all, depending on the academic source, the average patient will have fifteen to twenty-one hand-offs in any inpatient stay. That is a lot of opportunities to execute AIDET, RELATE, IHEART, or whatever mnemonic device an organization uses, not to mention a lot of opportunities to do service recovery. Of course, that is also a lot of opportunities to NOT use these things consistently.
There are people out there who are just not going to do the service work that you ask them to do; we can charitably call them “low performers” though they often go by other names as well, including some muttered under your breath. But my experience is that most staff believe in the importance of service and want to do a good job but lack the training or motivation to execute on those desired behaviors consistently. Setting aside the training piece, this essay will be on an important element in motivation.
The most common issue with motivation is the “I don’t matter” sentiment. This is often expressed by those who see themselves as marginal to the patient experience (like food service), those trying to minimize the length of clinical experience (like a 2am blood draw), or those tasked with something important right now (anyone associated with an ambulance arrival.) This conversation deserves its own attention, so I will hold off on that for the moment.
This essay’s topic is the second common issue with motivation: the “it doesn’t make a difference anyway” sentiment. The “doesn’t make a difference” sentiment is a deceptively simple claim. It centers on a general cause-effect claim often expressed as “I did what you told me to do and it didn’t make a difference in the scores, the patient’s demeanor, my own job satisfaction.” This is driven by the fact that patient experience is poorly understood by many on the clinical side and, frankly, the administrative side. This is more subtle than the usual “mints on the pillow” misconception. It speaks to a core confusion over what “doing patient experience” looks like, captured by the phrase “the spirit of the law versus the letter of the law.” It is the unacknowledged tension between the soul of patient experience and the delivery of patient experience.
This isn’t just an issue with getting people to act in the moment. This tension is at the heart of PX’s struggle to get attention and action at their hospital. It is one of the reasons why patient experience often lacks oxygen at the senior leader level. It seems less urgent than the balance sheet and much more inscrutable. To understand this, we need to look at the data that clinicians and hospital leaders look at.
Every hospital chases several different measures—some clinical, some financial, some service. What many people don’t realize is that the numbers that make up a hospital’s dashboard are a combination of population numbers and sampled numbers. Some are simple in their makeup, and some are complex. Some are easier to move, and some are harder to move. All of this means that tools needed to address them are different.
This is especially evident in conversations around patient experience. Clinicians and administrators often demand a level of rigor that the data and the service process cannot support. They want to know why the data shifted this month by 0.7% even though that is well within the margin of error. They will ask what date some new service process will be implemented, perhaps not appreciating that it will take weeks to get everyone trained, longer to get those behaviors hardwired, and still longer to see that work manifest itself in the data.
Meanwhile PX leaders often talk about the data and the process using language that seems slippery or broad, so the overall goal seems unattainable and the whole process just a stick used to beat them with. Staff hears “we need to be nicer” as if they weren’t nice before, or when the data doesn’t move, it was because they didn’t smile enough. Put more simply, both want to talk about ownership in PX work, but some want to talk about the letter of that ownership, and some want to talk about the spirit of that ownership.
Here is an example of this confusion. When we started to climb out of the COVID-inspired protocols that required us to don PPEs like Clark Kent in a phonebooth every time we entered a room or only talk to a patient through a mask and a face-shield while standing at least six feet away from them, we resumed our traditional service behaviors. The first to return was leader-rounding on patients (LRP).
For those who don’t know (or who use some other phrase for this work), LRP is the practice of making sure that at some point during an inpatient stay, a patient receives a visit from a organizational leader to have a conversation with the patient that is outside the normal elements and delivery of care. It is not about a pharmacy leader coming to talk about new medications, nor a focus on the 4 Ps (pain, potty, position, and possessions) during a nurse’s hourly round. It is an opportunity for a patient to meet a new face and for leaders to connect with a patient in a more personal way.
Since we needed measures to verify that we were doing something, the expectation was that all patients would be rounded upon at some point during their stay. Since this round was often done by an administrator or non-clinical leader, documenting this in the electronic health record was not an easy option. Instead, we would simply count the LRP for a month, divide it by the total discharges, and create a rough percentage of patients rounded upon. [Before my brothers and sisters of a statistical persuasion get riled up, I stress ROUGH percentage. We cannot let perfect be the enemy of good.]
Once we got this process in-place, we saw most hospitals were performing well. Now, a score of 98% did not really mean 98% of patients were rounded upon, since a patient admitted on a Friday afternoon and discharged on a Sunday morning might get missed, and that a patient with a laundry-list of comorbidities that kept them as an inpatient for seven days might get rounded on two or three times. Still, it meant that we were getting leaders in rooms and leaders were getting good at documenting this.
Quickly, the promise emerged. Since we had a question on the survey asking about a leader round, we could provide a proof-of-concept of the work. Consistently, across units, hospitals and across time, a patient who recalled a leader round had ten to fifteen percentage point increase on Overall Rating scores than those who did not. It became quickly apparent that if 100% of patients recalled a leader-round, the organization would be meeting their goal for Overall Hospital Rating. Now to be clear, even if a patient recalled a round, we were not guaranteed to get our desired 9 or 10 on Overall Rating. It wasn’t a panacea that would fix all ills. It just gave us an opportunity to address concerns in the moment, share wins, and leave patients with the sense that we really did care about them.
A problem, though, also emerged. It was the word “recalled” in the question. While organizations were logging rounds at 80%, 90% or even 125% LRP rates relative to discharge numbers, patients were only recalling the round at a 60% to 70% rate. Leaders were rounding but not leaving a lasting impression on patients, so those patients did not remember it when they took the survey a week or so later. Administration was so focused on the letter of the action—getting butts in rooms—that they did not focus on the spirit of the action—connecting with patients and getting their stories and insights.
From a system-standpoint, the lesson was missed. Leaders questioned the veracity of the self-reported log data. They challenged the sample size, or margin of error, or question wording. All are certainly worthy of conversation. But leaders missed the key middle step between walking into the patient’s room and the patient taking the survey. We were not making the LRP consistently memorable. We had hard-wired the behavior, we got the box checked, but we did not make a meaningful connection. Leaders will say that getting compliance with any behavior is half-the-battle. I will always respectfully disagree with this. Executing on a process without feeling, without being in the moment, without connecting to purpose is 0% of the battle. We cannot focus on implementation and deal with the memorability later. That is not how service works. Notice that in this story, there were no concerns about people not wanting to do the work. No one said, “rounding is stupid.” But there was a gap between those who focused on the act and those who focused on the purpose.
To address this gap in understanding and execution, I prefaced training on LRP as the one opportunity when a patient gets to tell us their story. Just about every conversation we have with a patient is about us telling the patient the OUR story. We tell them when they can eat, when family can visit, what care they will receive, when they can get up and walk around (*spoiler alert* never without supervision), when they will go to imaging and physical therapy, when they get to go home. LRP is to be the one time when we would get to hear the patient’s story. What are they seeing? What is waiting for them when they get out? Who do they miss? What excites them? Worries them? What needs do they have that we are not meeting? The real point of a leader rounding on a patient is to get the patient engaged and to gather stories the leader can share with the team both to motivate and help deliver care.
So when people say that the PX work “doesn’t make a difference” it may be because they don’t know what difference it is supposed to make. They may have outsized notions of its ability to create dramatic shifts in scores or the immediacy with which it will deliver on those shifts. They may think that it will eliminate all complaints and grievances. Or, maybe, they are just not connecting this behavior back to its purpose and are really delivering 0% on its promise of improvement.
To be clear though, as a PX champion, this is YOUR problem not THEIRS. You need to understand how they see the world. You need to frame training, follow-up, and motivation to act using their perspective, not yours. You are not mentoring fellow travelers. You are not training people who “already get it.” You are coaching people who secretly wonder what you do all day. This is not meant as an insult, but to help you define YOUR motivation in this work.
PX Matters with Joseph Snipp 
Leave a comment