Once More With Feeling, Part 1: How, not What

One of the biggest differences between patient experience and the rest of what happens in a hospital is that while the actual work can be comparable (essentially doing the right thing at the right time), its underlying architecture is not.  As I have mentioned in previous essays, this defines what success in service looks like versus other hospital must-haves.  When the same people are to deliver on multiple goals, the tendency is to use the same set of tools on the different targets, and this ends up putting the wrong emphasis on an issue and missing key opportunities to be successful.  In this essay, I will talk about the elements that make this work different from other elements in healthcare.  In the next essay, I will discuss things that we can do to correct or align the work, so the same staff can succeed at different targets.

Perhaps it is a lifetime of discussing experience with clinicians, but whenever I drive closely to the centerline that separates service and clinical quality, I feel compelled to provide the following clarification in order to explicitly state that I am staying in my lane.  In talking about the difference between two or more things, it is our human nature to want to rank them on some scale of importance or difficulty.  In this case, when examining how clinical staff treat quality and how they treat service, some may feel like I am denigrating or dismissing the work in one lane and prioritizing the work in the other lane.  That is certainly not my intention.  Delivering quality care is not easy.  If it were, The Joint Commission would not deliver citations.  We would not have to review sentinel events.  Saying that these things are different is not implying better/worse, easier/harder or important/unimportant.  It only means that they are different.  A nail is not a screw.  One is not better than the other, but you wouldn’t use a hammer to insert a screw.  If, in this essay, you feel like I am playing favorites or minimizing complexities, feel free to call me out in the comments.  With that out of the way, here are the three ways that service work is structured differently than quality or clinical work.

Need for Consistency

While all areas in a hospital require consistency in what is being done, because service is so readily visible to patients and families, it puts a premium on consistency in how the work gets done.  Given the number of hand-offs in any care setting, it is critical that each of these hand-offs are done expertly and that each staff member delivers the same high level of attention because any variation in that delivery is highly noticeable.¹  This is about setting up and then maintaining a patient’s expectation. 

The average inpatient stay is about four or five days nationwide, so, depending on 8- or 12-hour shifts, a patient is going to have as many as eight to ten different nurses.  If only one of these nurses is especially friendly and explains things well, it highlights how mediocre the others are.  To be clear, this is not about the clinical expertise of these nurses.  During that stay, I would expect that all are delivering high quality care.  But if all are not delivering high quality experience, it is noticeable.  After all, there is only a TV, a clock and a whiteboard in the room to distract them.  Further, the dirty little secret is that patients will often let that perception of the staff alleviate or bolster any concerns they have about the quality of care. 

I was visiting a friend who was in the cardiac ICU.  She asked for something and when she didn’t get it and asked again forty minutes later, the nurse said, and I quote, “You are not my only patient.  I can have you transferred to another nurse.”  It is impressive to get both a threat and a passive-aggressive dig in two short sentences.  At shift change and she did get another nurse, that nurse was very engaging.  She listened, did not interrupt, and repeated things back to the patient to verify comprehension.  I am confident that both delivered the same level of clinical care, but the fact that the second was wonderful actually made the whole unit feel worse.  If everyone is rude, one might explain it away as the stress of keeping people alive in an ICU.  But with one nurse being fantastic, then they all can be fantastic.  It is just that some don’t choose to be and management doesn’t care.  (But more on that in the second part of this essay.)

Less obvious opportunities

Everybody knows that a yelling patient or family member is a problem.  It doesn’t mean that we can satisfy them (or even that we will try), but it is an obvious issue that should be addressed.  But contrary to how it feels sometimes, these patients are a minority of the patients we have.  We have no excuse but to execute our service work or even service recovery work with these patients.  But the biggest problem most hospitals have is not managing that squeaky wheel, that barking dog, that flashing red light.  The biggest problem is that there is a quarter to a third of the patients who are not noticeable, but are the key to service success and they are receiving little attention.  These patients do what we ask them to do without comment or complaint.  Sometimes they will even push away any offered assistance with a “oh, I know you are so busy…”  They are low stress for staff and as a result are low impact on the staff’s day.  After discharge, though, they are also the ones who may not follow up on a post-discharge appointment, may not take their prescriptions as stated for the entire run of the medication, or may not give you the desired top-box on the service survey.

In the diagnostic space, there are also patients who have obvious needs and others that present a puzzling or less-obvious path for treatment.  But at least in the clinical space, there are best practice advisories (BPAs) that can call out screenings or medications that may be overlooked.²  They were originally designed to assist with pernicious and deceptive problems, like sepsis, where the underlying logic in a BPA may catch a potential case before the providers do.  As I type this, I know that there are some clinicians rolling their eyes, since the proliferation of BPAs and hard-stops in the EHR can be as frustrating as commercials you cannot skip on Netflix or Pandora. 

I know that some patient experience vendors are trying to create service BPAs in the electronic health record, but until that becomes something tangible instead of vaporware, we have no check-engine-light to alert us to potential service opportunities.  This means that service is especially reliant on staff keeping their eyes and ears open for places to deliver.  Every service plan has “always” activities and “never” activities, but consistent execution of successful service activities still requires keen attention to opportunities before they blow up into a full-blown service recovery need.

Patient-tailored communication

On the clinical side, there is a lot of conversation about patient-centered care, the notion that the various options and elements of care need to be discussed with the patient and so their needs, expectations, and desired outcomes can be factored into the plan.  Having the patient at the center of the conversation is a must-have.  But within this, there also must be patient-tailored communication.  Just this morning, I went with my wife to a brief outpatient procedure.  During the pre-op, the nurse asked Katie to repeat back to her what the procedure would entail.  Being a nurse herself, she described the event in very clinical terms.  This set the tone for the subsequent pre-op work.  Had I been the one in the bed, I would have said, “You are going to jab me with a needle to temporarily numb a nerve.”  In that situation, the conversation would have likely taken a different path.  It would have ended in the same place, but the process and the language would have been tailored differently for me versus my wife.  This is more than adapting material to a patient’s educational level.  It is about adapting it to the patient’s desire.  For example, some patients want all the gory details and others definitely do not.

While none of these elements are alien or unaligned to other workflows in a hospital, they are also distinct and not subsumed under other workflows.  In essence, one will not be compliant with this work simply by being compliant with the clinical workflow.  One can accidentally succeed with service, but hope is not an action plan.

¹In fact, I would say that delivering a consistently mediocre experience is better than having one or two amazing staff members, because that awesomeness highlights the variation.  Those peaks and valleys are the things that patients remember.  Being mediocre means being forgettable, which while not helping perceptions, at least doesn’t tank perceptions.

²For those who don’t know, a BPA is an alert that pops up in the electronic health record when a list of criteria is met.  It is designed to help guide care providers in certain situations.  I (and Google) have a lot to say on this topic, but for the moment, I will leave it there.