As previously discussed, one of my skills is in patient experience. My wife is a nurse, and she has worked in Quality, Risk and Compliance. (I use capitals there to identify them as departments and not simply tasks.) I remember the first time I told her a story from patient experience, and her response was not what I expected. This heartwarming story I was telling of a staff member going above-and-beyond for a patient filled her with questions and concern. This is when I first realized that in most hospitals, the PX folks and the Risk folks are like the Sharks and the Jets. They may not be openly hostile, and they are not looking for ways to antagonize the other but scratch the surface and you see the tension and conflict.
The point of this essay is not to talk about who is right or wrong, but to highlight something that often does not get discussed. If you have ever sat in a meeting and wondered why it seems like the organization is not aligned, well, it is because sometimes it is not aligned. Risk and PX is just an example of this. Often these tensions are not called out, either because they are not noticed, or because talking about them in the context of a broader conversation will start a fight. Any organization working towards satisfying the quadruple-aim—improving quality, costs, employee satisfaction and population health—knows that by prioritizing one thing you push attention away from another. This is not to say one is right or more important, but simply to say that there is a need for balance here. If you lean too heavily towards one, you will blow a hole in another.
Risk and PX can work together and have aligned interests, but this doesn’t mean that they do. If we use them as an example, we can understand how conflicts arise in hospitals and create some insights on how to have conversations on competing needs while generating more light than heat. Perhaps it goes without saying, but this PX vs. Risk discussion will be filtered through these eyes, which know a lot about service, but almost nothing about risk. Comment if you feel I am putting my thumb on the scale.
I have attended a lot of patient experience conferences, and I have learned a lot of useful things. I have also presented at a lot of conferences and, with hope, have taught some useful things to attendees. But there is one staple in the standard PX presentation and conference that I cannot escape no matter how much I try. It is that story that is designed to elicit a very specific and base response; it is designed to make you feel sad in how someone was treated, or horrified that someone allowed someone to be treated that way, or smug because you would never treat someone that way. Maybe it is a story that makes you feel good that someone did something nice for someone else and that it all worked out in the end …and they lived happily ever after. If the presentation is good, that story becomes a call-to-action that an organization uses to change policy or procedure and thereby prevent that situation from occurring again. If the presentation is not as good, the story hangs there as cheap emotional manipulation. It is the conference presentation version of click-bait. It gives you nothing but a visceral response. It is empty calories.1
Any story of a staff member going the extra mile for a patient falls into this heartwarming category. The presenter makes the point that the staff didn’t do this because they had to, but because they wanted to. I have heard stories about staff driving a patient home at night during a snowstorm, or, going to a patient’s home and watering their plants, or, staying late and reading to the patient until they fell asleep. I recall an especially dramatic story where a couple of nurses went to a patient’s home twice a day for a week to get the patient’s mail and feed the patient’s cat. I remember that it was a forty-minute round-trip and required hopping over a small stream to get to the patient’s front door.
These are the sorts of stories that make PX folk tear up. They celebrate staff so committed to their mission that they would make a sacrifice just so a patient can focus on getting better and not being concerned about their home or their pets. These are also the stories that give Risk nightmares. (Stories like this probably don’t do much for Legal or Employee Health, either.) While the PX folks see a wonderful silver lining in the day-to-day work full of grey clouds and anxiety, the Risk people have a swirl of follow-up questions:
- What if a nurse fell in that stream and hurt themselves?
- What if a nurse hit a deer on the way to this remote house?
- What if the cat ran away, or, worse, died?
- What if something went missing from the house?
- Should a staff member really be going through a patient’s mail?
- Should they be taking responsibility for accepting a registered letter or package?
So as PX folks are wired to focus on what they can do to make things better, Risk folks are wired to focus on minimizing opportunities for things to get worse. If they are not careful, PX looks at Risk as a dour group primarily focused on reducing harmful events by sucking the joy out of life, and Risk looks at PX as a bunch of hippies handing out hugs while being completely untethered to the reality of healthcare.
When these groups bump heads, it seems like the organization is not aligned. Further, if you feel like the other side is being willfully difficult, it can temper your interest in finding a solution. But are they being willfully difficult, or are you striving for the same goals, just using different words? Consider these comments as you navigate the waters.
Assume good intent. A big mistake in life and work is that we ascribe to malice that which can easily be explained by oversight. While there are exceptions, a vast majority of the time a vast majority of people are not scheming on how to make your life difficult or looking for ways to hurt your feelings. It can just feel that way. This is not to say you should necessarily ignore insults, but to pause a moment and determine if that comment was meant as an insult. Often it was not. We all may have different responsibilities, but we all want what is best for our patients and our staff. If you start by NOT assuming that Risk has no heart and PX has no brains, you will be ready to consider a real solution.
Remember that institutional memory is fallible. One of the largest problems in most hospital systems is that there is no institutional memory for the things that matter, but incredibly powerful institutional memory for the things that don’t. In working with hospitals and their compliance with civil rights, patient access, disabilities and language barriers, I will first ask the question “How did you access compliance last time?” That question often gets blank stares because it has been three, four or five years since they discussed this topic and the people who did the work aren’t here anymore. On the other side, when I ask a staff member why they acted as they did when presented with a Service Animal, they will say, “That is what is in the policy.” No matter how many times I point out that what they did is NOT in the policy, that belief remains a pernicious weed poking through the concrete all the time. We need to be aware that “this is the way we have always done it” may not be accurate, or may no longer be aligned with policy, but it can drive behaviors.
Call out with kindness. If we assume good intent and remember that memory is fallible, we need to approach conversations with beneficence. I would say that it goes without saying that you shouldn’t ask “Why are you an idiot?” except that I have heard similar questions asked by leaders to staff or even other leaders. Better is to understand why someone did what they did without judging what they did. Sometimes people can be guarded even if you ask them to explain behavior gently. While you need not be codependent, if you preface a series of questions with a “Help me understand what you did…” or “Let us review the policy for clarity…” you can create a more collaborative environment and avoid some defensiveness.
Find a solution, without being the solution. Specifically, with PX and Risk, the conflict is not over the outcome, but the process. During COVID, a lot of hospitals suspended their valet parking service, so patients were left to navigate the hospital parking lot on their own. This meant not only surviving the elements, the potholes and the other drivers, but also having to manage the transfer out of their vehicles while using their assistive devices. It was not unusual, then, that a patient pulled up to the front door looking for help from a volunteer or greeter. Though perhaps not being trained on transfer, they would still try to help, often hurting themselves in the process. They often report up through patient experience, so it is in their DNA to help and make things better, even though a rational person might observe that nothing positive happens when an 80-year-old volunteer tries to help a bariatric patient out of their care. When asked why they did not call for help, they might say “I didn’t know who to call” or “It was just easier to do it myself.” While these encounters may make good tear-jerking stories, a lot of the time, staff act the way they do because (a) they didn’t know there was a process, or, (b) the process is too cumbersome for them to use. This means that:
- PX needs to investigate what policies and procedures exist to tackle an issue before just setting off on their own. Patients have left pets at home before, so read the appropriate policy before starting down a path.
- Risk needs to understand that if a procedure is too burdensome or complex, people will ignore it or if the event only rarely occurs, people may forget what the process is. Asking staff why it was not followed will determine if streamlining or training is required.
In this case, the solution was to provide the greeter with a sheet with a short summary of the process along with useful phone numbers in big bold font while reminding staff that transferring patients is a risky event that requires special training.
Everyone wants to deliver on a positive experience, but it is the lack of clarity and communication of goals that causes the most conflict. If we start every conversation by articulating our motivations and goals, we can reduce the amount of confusion and tension the conversation generates. So, for example, explicitly stating “I know that you have the patient’s best interests at heart, but please understand that I have your best interests at heart” can start a conversation out on the right foot. And if you are one of those people reading this and saying, “Yeah, but Joe, you don’t know the knuckleheads we have here,” I would ask you to look in the mirror and evaluate your ability to communicate effectively.
1Shows like Friends, Mad About You, Seinfeld or Sex and the City were described as Work Porn, since they never addressed how a group of people, many who were only marginally employed, could afford massive two-bedroom apartments, could afford to eat out all the time, and always had the best clothes and shoes. So, I will often refer to these conference stories devoid of specifics or real-world concerns designed to instead leave you with some vague emotional response as Experience Porn or Sadness Porn.
PX Matters with Joseph Snipp 
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