I Don’t Matter

I was talking to Hope last week and during our pre-work chit-chat, she mentioned that she disagreed with my appreciation of the Beryl definition of patient experience.  As she got name-checked in the first essay on this blog as someone I respect, I thought it was a topic worth exploring.  As it dovetails with last Friday’s blog on motivation, now seems as good a time as any for this exploration.

For those who don’t recall and are too invested in this essay to go back and read a previous one, I said that I liked the Beryl Institute definition of patient experience (the sum of all interactions, shaped by an organization’s culture, that influence patient perceptions across the continuum of care) and she said that she hated it.  For the purposes of this essay, I want to focus on one key frustration she had.  (She is welcome to hold forth on any other reasons in the Comments section.  If she wants to dedicate an entire essay to the topic, I am happy to post or cross-post it here.) 

Hope does not like the opening clause “the sum of all interactions” because she feels that this implies that all interactions are equal.  But in her view, they are not.  People come to healthcare to address a specific issue, and they will prioritize some elements of that interaction more than others.  Namely, the clinicians will be more important to the overall patient experience than other staff they encounter.  Indeed, the clinicians will outweigh all the other elements of the experience combined.  Imagine going to a doctor’s clinic.  As you enter, the registration person is very welcoming.  The next is the rooming person and that person is friendly and engaging.  You then see your doctor, who you feel is rushing you and, frankly, is a bit of a jerk.  Perhaps following that, a nurse or phlebotomist comes int to draw blood sample and they are compassionate.  Three out of four people encountered were welcoming and present.  But to you, the patient, does this feel like a 75% experience?  Or do you say that the experience was bad because the doctor was rude and the rest was not enough to counterbalance the doctor’s behavior. 

So not all interactions are equally important.  The experiences tied to the explicit reason a patient comes for care weigh heavier than any ancillary elements.  Perhaps if the definition said the weighted sum of all interactions… Hope might be happier.

I understand and agree with Hope on her concern with the definition, but I am not as irritated as she is because I am not diving deeply into the specific words and clauses.  For example, “culture” is another word that makes sense in the abstract but can get very grey very quickly when you put it under the microscope.  None of this bothers me because to paraphrase a Seinfeld episode, mission statements are like gossamer, and one does not dissect gossamer.¹

The real issue is how this perceived equality or inequality of experience responsibility manifests itself in behavior.  We don’t want to excuse those in the “I don’t matter” crowd from the conversation about how to add zhush to their work.  We also do not want to hyperfocus on these constituent elements of the experience because they are seen as easier than addressing the service elephants in the room.  Simply, it is easier to lecture the food service staff on service than it is to lecture the physicians. 

Everyone will acknowledge getting doctors and even nurses to do what they need to do with every encounter every day is challenging.  But when we do not do that, and only chase the easy stuff, we deceive ourselves into thinking that the easy stuff is just as important or is all we need to do to be successful, when it is not.

Now many organizations thread this needle by avoiding it.  Stop me if you have heard this before—an organization will cascade service expectations down to individual leaders.  The senior leaders may not have time or attention to worry about how security or food service is carrying the cultural standard.  But the leaders of those departments can do that.  Yay!  Problem solved!  On to other more pressing issues…

Except that, if there is no support for those fiats, they are not likely to yield the results that you want.  Let us examine five hidden problems with this broad solution.

The reality of the labor market:  The reason why a lot of leaders do not want to mandate patient experience behaviors from clinical staff is because they are worried that those nurses, doctors, technicians will jettison for another job somewhere in the world where they are NOT asked to do those things.  It is true that recruiting is a challenge for clinical staff, but it is equally true in other areas of the hospital.  Frankly, it may even be more problematic.  After all, broadly speaking, a doctor is going to be healthcare wherever they go.  But an accountant or a member of security can leave a hospital and be an accountant or security guard for any other industry.  There are plenty of facilities that need facilities managers.  Even housekeepers can keep house at hotels, spas, or even houses.  In fact, when you factor in pay and the more stringent requirements that hospital cleanliness requires, a housekeeper could make more money and be less stressed anywhere else than in a hospital.  You are not completing for employees with other hospitals, but with other industries.  The pressures of a leader to be less aggressive with PX are just as great in all areas of the hospital. 

The reality of the PX work, the manager: Managers, especially in the support fields, may not have the skills to train for service.  They are focused on budgets, efficiency, and absenteeism with an at-times transient workforce.  They may not know what to train their team, let alone how to train them or how to balance these demands against getting the work done with a small staff.

The reality of the PX work, the staff:  The work support personnel do can be complex and under-appreciated.  I have talked to a number of cleaning crews and one of the biggest challenges they face is that, while they are doing their job of emptying trash and mopping the floors, they will get a call to help turnover a patient room after discharge.  Since boarding in the ED is a chronic problem across the country, getting rooms ready quickly for a new admission is critical.  If you talk to them, you will find out that they like working on some units and for some nurses better than others, mostly because of how they are treated.  So asking them to be service-forward, when they don’t get that treatment from other employees can be a difficult thing to do.

The reality of not making it worse: I worked with a hospital in rural Nebraska, and I was talking with the housekeeping crew.  At this hospital, the housekeepers were a group of Hispanic and Eastern European grandmothers.  When I asked them what they did when they went into a room—did they introduce themselves, narrate their work—one lady said that they were told to never talk to the patients.  As I investigated, it was true that they were told to not engage with the patients, but no one could tell me why or where this rule came from.  The reason was lost in time, but it was still enforced.  Chances are, a housekeeper said something to a patient once that the patient didn’t like and they complained.  In the game of Organizational Telephone, the request to “Mind what you say” got corrupted to “Just don’t talk.”  I am asked to talk to them about how to be better at PX, only to discover that these little old grandmas are not the problem.  They loved the opportunity to chat with patients as they performed their work.  The organization was the problem.  In a universe where HIPAA is often a stick with which we beat people, it is not surprising to realize that we sometimes encourage our staff to be disengaged.

The reality of metrics: Everyone knows that what you measure matters most.  These support teams have a lot of things they measure—mostly having to do with labor efficiencies and other expenses.  They do not, however, have many or any patient experience measures.  There is a question about cleanliness on the HCAHPS survey, but no food service or security question.  No questions about lab or imaging experiences.  So, if a department only has economic measures, is it any surprise that that is what they focus on?  Further, when these departments ask for a question to be added to the survey, they don’t get one because survey length is always the concern.   Departments, discovering that they cannot get a question added, will often create their own home-brew survey that they execute under the radar which they won’t broadly report, for fear that they will be told to stop doing it.  Since the dashboard is about accountability, not giving a department a measure to post in their dashboard is the same as telling them not to worry about it.

When you add all of this up, organizations will task department leaders to work on service, but they don’t aways give those leaders the real support they need.  And, just as the lack of metrics prevents them from motivating their staff, the lack of metrics means that the senior leaders will forget about this directive as soon as the next dashboard comes out.  If you interview those leaders, you will discover that most feel left out on an island when it comes to service and the only real difference is whether they like that anonymity or not.

We might want to create weights relative to important interactions, or we may say that some interactions are asymmetrical because they can only hurt and never help, or vice versa.  But the support staff are not invisible.  In many ways, patients are more cognizant of the support team’s work, because they may not know the difference between an MRI or a PET, an EKG or an EEG, but they do know what good food is, what a clean room is and whether that room is too hot or too cold.  I will concede to Hope that a simplistic reading of this can lead to broad assumptions and concerning actions.  But I hope that she will agree with me that these groups are both tricky to motivate and important enough to put in that effort.  It is one thing to think you are not important, but quite another to be told that by your organization.

¹ If your first response to this is reference is “I like the kitty”, I can relate to the way your brain works.  If you want to know what the heck I am talking about, you can watch the Seinfeld episode, “The Cartoon” which is Season 9. Episode 13.