Once More with Feeling, Part 2: All the World is a Stage

In the last essay, I discussed how service is different from other elements of care, especially since those who are primarily targeted with execution of service may not necessarily have the fully developed skillset to deliver it.  In this essay, I want to explore important elements of service that leadership needs to consider in constructing a plan and expectations for staff to deliver an excellent service experience. 

Again, before I begin, this is not meant to be disrespectful to those who interact with patients in any care setting, be they clinical or non-clinical.  This is not a conversation about fixing what is broken, or what is not addressed.  This is a conversation about how to tweak the work to make sure all people delivering care are supported in doing the work we ask of them.

Service Excellence is not Service Recovery

The quickest way to determine if a leadership team is really focused on service excellence is to task them what the key elements of service are.  Often, people will respond with processes to address problems, from service recovery toolkits, to having the patient advocate on speed-dial.  This is not especially surprising because most leaders and staff are far more keenly aware of crabby, vocal, miserable patients.  These are most noticeable and are the ones that are most likely to crater a normal day.  But fixing problems is NOT service excellence. 

Service recovery is certainly important.  If you break a glass, you must sweep up the broken glass.  But there are several reasons why a focus on service recovery will never get your patient experience scores to climb.  For example, service recovery is:

• Individual: Because service recovery is focused on fixing a problem, it is by definition focused on an individual patient.  Even if the problem covers multiple patients (like delays in the emergency department) the solution is still individual.  A global update to the ED waiting room may inform, but it will not address the need for service recovery at a patient-level.  If you have been waiting for five hours, seeing someone else get called back is not likely to make you feel any better. 
• Particular: Since service recovery is addressing an individual patient, it will be focused on that individual patient’s needs.  One solution for one patient may or may not fix another crabby patient.  Even if you have a menu of service recovery options, there is no one-size-fits-all model for fixing problems and it all starts with talking to that one patient. 
• Retail: Service recovery addresses one person’s concern, meaning that there are no collateral benefits for providing service recovery to a patient.  One complaint leads to one solution leads to one happy (or less upset) patient.  This, as opposed to one solution that leads to multiple happy patients, which I refer to a wholesale approach.  Imagine that there is one patient who is a holy terror and you need the nurse, the nurse manager, the patient advocate, the director of nursing and the chief nursing officer all going into the room to manage away the problem.  After several meetings and a bunch of tools from the service recovery toolkit, that patient is finally mollified.  What impact did all that work have on the other thirty patients in the unit?  Best case scenario, it had NO impact on other patients, because what you gave that one crabby patient was not visible to other patients and had no spill-over to them.  Worst case scenario, it actually made those patients’ experiences worse.  So much time and effort were expended to address one patient meant time and effort NOT delivered to other patients. 
• Reactive: Service recovery starts after the problem happened.  We don’t call housekeeping before we break a glass.  This also means that it is scattershot, chasing random problems across the hospital or clinic.  Not only is this emotionally (and perhaps physically) exhausting, but it also doesn’t do anything to prepare for tomorrow’s list of issues. 
• Not impactful on the data: The biggest issue with service recovery is that there are those who see it as a viable way to move the data, at least in those organizations where net promoter scores are used.  This issue here is that service recovery will not likely impact the net promoter score in any appreciable way.  First, because outside of the emergency department, there are very few patients who give a 0-6.  Second, it is unclear if providing service recovery will move a patient from a 0 or 1 all the way up to a 7, let alone a 9 or 10.  So, a reliance on service recovery to move the overall needle won’t work.  Factoring in response rates, the story is even more grim.  While service recovery is important, it will not change your scores markedly.¹

If you want to create a plan that addresses most patients through the consistent execution of one action plan, you cannot do this through service recovery.  You need to do this through service excellence.

 Everything is On Stage

While a lot of clinical work is done behind the scenes, service is exclusively what a patient can see.  (See the essay on Brown M&Ms for more on this.)  This includes the stuff that is not designed to be seen by a patient.  Indeed, a lot of what patients see is what we do while we are doing other things, and a lot of what patients see is when staff do when they think no one is noticing. 

The simplest example of this is the non-verbal component to any communication.  The tone of voice, the words we use, even the direction our feet are pointing in can tacitly tell a patient the importance of the conversation.  There is plenty written on the importance of sitting versus standing or standing at the bedside versus standing at the door, or using first names, or not interrupting, or introducing yourself, so I will simply say that all these things speak volumes.

Less obvious, though, is how we speak to our fellow staff.  We spend more time with our team than we often do with our families.  We speak to our fellow staff, having a wealth of context, in a way that ideally builds camaraderie.  But without that context, the language we use can seem insulting or offensive.  When on the inpatient floor, or in the ED or at a clinic, I have heard staff calling other staff “Miss Perfect,” “Queen,” or even “Bitch” (in both one- and two-syllable forms).  I heard a nurse called “Juanita” (she was Hispanic and her name was not Juanita).  I was appalled, not at the words themselves, as in each case, it was a term of endearment that the staff embraced.²  I was concerned because I heard them and I didn’t know the context.  Likewise, now knowing the context what are patients and family members to make of the team dynamic?   They may be forgiven if they have serious concerns about teamwork and about their loved ones getting appropriate care.  They hear language that they define as unprofessional at best and aggressive at worst. 

Because they live in the same environment, the leaders often don’t even notice the language.  If they do, they may feel like they must pick their battles with staff and allowing some horseplay in the name of unit cohesiveness seems a small price to pay.  Either way, this is not likely an agenda item on any unit huddle or a bullet point on any performance appraisal.  So, even if that leader is making sure that there is consistent execution of service work (like handoffs or rounding), the value of these things is muted by these unintended perceptions. 

In some cases, these behaviors can be obvious or over-the-top, but even small visual cues that take place on stage are noticed and evaluated by patients.  Even when we are doing things right, the right actions can be misunderstood.

• I remember visiting a floor after several patients complained that “the nurses were always looking at their phones” only to discover that they were not phones, but hand-held communication devices to assist in call-light response, team communication, and timely delivery of care.  To the patient’s eye, though, it was a flat, palm-sized tablet in a protective case that looked a lot like a phone. 
• I was at a high-volume emergency department that just went through a massive update and redesign.  The redesigned the ambulance bay, so it did not compete with patient parking and walk-in access.  They sound-proofed everything, even using furniture that was designed to dampen noise.  They redesigned the flow around a hub, so that staff did not have to run from one side to the other side to get medications or chart or check on patient vitals.  Their patient scores did not go up.  In fact, their Timeliness of Treatment score went down.  It turns out that they were too good at reducing noise and the flurry of activity.  When I toured, they had a full waiting room and all rooms, except one, were full.  They had just received two ambulances in the past hour or so.  And the back of the house was quiet and calm.  It was ideal.  Except that the patients in the waiting room didn’t see or hear any ambulances arrive and, after waiting four hours to get called back, they see a quiet space with no one running around.  So their first thought is, “these guys aren’t busy, why did I have to wait so long?”

It is important to realize, though, that no one can be on stage all the time.  There needs to be off-stage locations where a staff member can kick the trashcan, shout a profanity into a pillow, or just find five minutes to take the mask off.  A leader cannot demand a staff member be focused on their deportment when on the floor, if they cannot give that person some space to recharge or decompress when the real world presents itself.  I have seen some hospitals embrace this, buy creating rooms no larger than a closet with a comfy chair and a noise machine to provide a brief refuge from the storm.

Focus on Setting Expectations

I certainly understand if these stories just aggravate you.  Patients get anxious when there are a lot of loud noises and people rushing about.  Patients get frustrated when the space is quiet and staff seem calm.  Patients are irritated when their call-light goes unanswered and they are irritated when staff use technology to improve response time.  My point here, though, is not that you are damned if you do and damned if you don’t.  My point is that you can change process, workflow or access, but if you don’t also understand how a patient will see this and focus on setting that patient’s expectations, you won’t harvest the value you expect.

One classic element from the past decade was the federal rules about giving patients access to their medical records and information as well as an opportunity to ask questions or get medication refills.  This was mostly accomplished by hospitals creating patient portals, where the patient could review lab results or read physician notes directly.  They can often email questions to their providers or schedule appointments.  For many, this is a significant satisfier.  When I get a blood panel done, I can see my results as soon as they are available.  I don’t have to wait for my doctor to call, and my doctor doesn’t have to take time to call me to tell me that all things are normal. 

But, if an organization did not dig deeper into this marvel, they would miss opportunities to help set patient expectations.  Patients have expectations about how quickly they should get a response to an email and therefore become annoyed when their emailed question to their doctor does not get an immediate response.  Patients can see their test results before their physicians do, but follow-up questions or next steps still need to be filtered though the physician’s workflow.  This can have traumatic consequences.  A pregnant woman came into a busy emergency department with some concerns.  She had access to her chart on her phone, so, she saw the test results immediately and learned that she lost her child.  Then she got to sit in a sterile ED exam room, completely alone for 90 minutes before anyone came in to talk with her.  Without a workflow, the process can make things worse.

Patients don’t know what the heck is going on.  They are in an alien landscape, with people using alien language and doing tests that often don’t make sense.  Even those with some understanding can imagine they are more knowledgeable than they are and know just enough to be dangerous.  Not given a roadmap, they will set their expectations for themselves.  It will be based upon what they have heard, what they have seen on TV, or even past experiences, which all can be misremembered or out of context.

Without helping patients set expectations, they will set them all on their own and these will almost always work against you.  We often dance on a razor’s edge.  There are two types of patients: those that think they are less sick than they really are and those that think they are sicker than they really are.  From our patients’ eyes, we have never discharged a patient on time.  We are either keeping them here needlessly (probably to pad the bill), or we are kicking them out the door when they still need help.  This razor’s edge—where we fall on one side or the other—in large part is because we have not set expectations with our patients.  We have not helped them understand what they are seeing.  Going back to my examples, imagine if a nurse said this to a newly admitted patient.

• “This may look like a phone, but it is really a very cool piece of high-tech equipment that allows me to give you the best care as quickly as possible.” 
• “I know it seems like we are not busy here, but this appearance is to help keep you calm and assure you that your care is important to us.  We are like ducks, it looks like we are serenely gliding over the water, but trust me, underneath we are paddling like mad.”

If we are to ask staff to deliver on service with feeling and attention, we need to help them develop the space and the support they need to execute on these things.  Most staff want to deliver but without attention to the time and space, or considering the patient’s perspective when we create workflows, we might be setting our team up for failure.

 ¹I started building out an example of the math here, and it exploded beyond what a footnote should be, so I will create a separate entry explaining why this math doesn’t math and service recovery won’t touch overall survey results. 

²For those curious, I did find a moment to talk to “Juanita” alone to verify that she was comfortable with this nickname and she was.  She told me the evolution of the nickname, and it was pretty funny, though definitely one of those “you had to be there” stories.