Nothing happens in a vacuum. As I write about analytics and philosophy of patient experience, I try to put these things within context, since it is not helpful to start any conversation about fixes with all the hard problems assumed away.1 The reality is that all the work that a hospital does doesn’t happen independently of all the other work. There may be different teams working on different tracks, but a system must prioritize the work. This is not concerning; it is life. What is concerning to me is what happens to service initiatives in this space. When prioritization always favors some work over other work, the usual model of Now, Next, Later becomes Now, Next, Never. All initiatives must be cognizant of other work being done on different targets, so this essay is not meant to be ‘woe is PX,’ so much as to call out important trends outside of service that can have impacts on service work. I will leave it to you to judge if it is more thoughtful than simply ‘old man yells at cloud.’
The Balance Sheet
Money is always going to be the 800-pound gorilla, but recently it may have grown to be a 1,000-pound gorilla. Several things impact the profitability of hospitals, from their location or payor-mix to their status as a for-profit or not-for-profit entity. There are smarter people than me who can speak at great length on this. I will focus on just a few things that are consistent across the board and important to service work.2
The average hospital has never had sexy operating margins. Not-for-profits tend to have an operating margin in the 3.5% to 4.5% range. For those who don’t know, this is on the low end of margins in the broader economy, where, depending on the industry, the average is more in the 10% to 20% range. The pandemic was not kind to healthcare. While the industry has seen their margins improve after cratering during the pandemic (especially if you remove government subsidies), as of 2023, almost two-in-five hospitals (39%) have negative margins and one-in-five (22%) had a margin of -5% or worse. Compare these numbers to the rate of inflation, which pre-pandemic hovered around 2% during the eye of the storm averaged 6.8% and over the past three years is stilling about 3%. So, comparing this to the average operating margins, the average hospital is basically treading water. For those with debt, this means that they are in a rather difficult hole to climb out of.
This is not about politics, and I am not making any broader statement about costs of healthcare. I am simply pointing out that right now, the average hospital is keenly aware of their balance sheet and are doing everything they can to manage their debt to survive or to make themselves attractive for purchase. So, everything from a new MRI machine, a new orthopedic surgeon, or LED lighting in the hallways is squeezed through the return on investment (ROI) sausage-press. Service does not function well in this environment, since its value is understood more than it is quantified. Given the fact that healthcare usage is driven largely by need (emergency department) or insurance coverage (cadence for yearly appointments or screening tests), as well as other available options, it is difficult to draw a causal link between an improvement in patient satisfaction and an increase in usage. This doesn’t take into account that some usages are more profitable to a hospital than others.3
On top of this, senior leaders may give patient experience lip-service but aren’t necessarily convinced of its power. I was talking to a leader in downstate Illinois and asked him why he was not struggling with finding nurses. I thought he might talk about the great working conditions, or some pay advantage. Instead, he said that the interstate that went through town was under construction and the exit ramp to their competing hospital was closed so the nurses switched hospitals out of convenience for their commute. He further said that once that construction was completed and they moved on and closed the exit ramp that served their hospital, he expected to lose all the nurses, who would hop to the competitor for convenience. I was struck that he didn’t consider his hospital as a better place to work. He didn’t consider selling his hospital as a better place to work in an effort to keep the staff. He simply shrugged his shoulders and essentially admitted that service (at least for employees) didn’t matter.
This example may be extreme, but it highlights a sentiment held by many leaders. They more easily understand the value proposition of opening an outpatient imaging center than understand the value proposition of making the service (employee or patient) better. If they don’t understand it, then they cannot quantify it. If they cannot quantify it, then they are uncomfortable talking about it. Here is a test. When you listen to the leaders in your organization talk about your hospital, clinic or system, count the number of times that they speak about the pillars—service, quality, people, finance, and growth. If your experience is like mine, you will notice that finance and growth far outpace any other topic. Quality and People come in a distant third and fourth and service is rarely the topic of conversation. For the past 25 years, when asked what they can do to improve service, I would tell senior leaders the same advice. I would tell them to mention service as a motivator for the organization. I would encourage them to say things like, “We are able to be profitable and grow because our patients think we are the best in our community” and 25 years later, I still rarely hear this as a talking point. Attention is currency, so if you only talk about finance and growth, don’t be surprised that this is the only thing people focus on.
As a result, many patient service initiatives die a quick death, since the only numbers are on the cost-side of the ledger. I can tell you how much providing additional office hours after 5pm or on the weekend would cost. I can tell you how much it would cost to provide bottled water or coffee to patients/family in the waiting room at a nursing unit, emergency department, or clinic. It is far more difficult to quantify what the return is on those things. Even when leaders consider clinic usage on off-times, they rarely consider if that usage was merely more convenient, or, if that usage opened care to patients who were otherwise shut out of the traditional office hours. Even when one can show a collateral benefit (like when I showed that patient self-rating of their understanding of discharge instructions impacted their likelihood of 30-day-readmission), leaders often want a more quantifiable savings to the work.
This leader attitude has always made getting time and treasure for service initiatives difficult. The current climate where a significant number of hospitals are hanging by a thread only makes this tension explicit. Service needs to figure out how to talk in these terms, or forever relegate themselves to the Never pile.
The Need for New
In helping organizations chart their course with service, the most-frequently-asked question I get is “What is new in patient experience?” and it is a pet peeve of mine, even as I know that the questioner was not trying to trigger me. There are always going to be new ways to approach or phrase service and there will be new ways to address service with patients, by adding more staff to the PX team, or by adjusting to new realities in healthcare. Usually, though, this question comes from a simple misunderstanding of what patient experience requires for success (from leaders) or simple boredom (from frontline staff.)
Leaders, especially those who have immigrated from other industries, seem to always want a new product to sell, a new thing to energize the employee or patient population. Now, two things about this are true:
- We need to be always considering how the changing landscape (good or bad) in healthcare needs a changing approach to service. Whether it is independent agents trying to poach the easy and profitable, or, it is the pernicious problem of boarders in the emergency department, we need to build a service structure to address it.
- We need to be continually looking for ways to energize and engage staff and patients because their loyalty leads to a robust staff and a healthy community.
But (and I cannot believe that this is controversial) you don’t establish longstanding culture by chasing after the next Labubu. You cannot keep patient experience ‘fresh’ and ‘relevant’ by day-trading strategies. I had a leader tell me that the problem with their PX scores was that we needed to switch from one mnemonic device to a different one. I responded that the problem was not the device; it was that people were not using it. What, I asked, made him think that switching would all of a sudden create a paradise of compliance and communication?
I know that there is a cottage industry of people hawking books and lectures trying to inspire movement in PX scores. I don’t mean to denigrate them. Heck, some day, I may be out there with a book and a message myself. In fact, there is nothing wrong with their message or their approach. My problem is not with the speaker, but with the listener. There is an assumption that patient experience approaches are like toasters. If it doesn’t work, you go buy a different one, plug it in and away you go! Except that there are two glaring reasons why PX approaches are different.
- Implementing a new approach requires more than simply plugging it in. As previously stated, service is visible and requires 90% compliance for it to work in moving patient perceptions. Take the size of your staff—clinical and non-clinical—and divide it by 20. That is the number of classes you will need to train the new approach. Multiply it by 60 and you will get the bare minimum of time needed to execute that training. Bonus points, if you meet staff where they are and offer sessions at night or over the weekend. Once it is trained, then the new thing needs to be implemented, which is making sure that staff can do it consistently and leaders are comfortable auditing and calling staff out on performance. Then consider the amount of time that is required to turn this new thing into a habit. It is not outrageous to consider that best-case scenario is six months to hardwire the behavior and probably closer to nine months or a year, depending on staff turnover. Of course, staff turnover means that this process never ends and that the training needs to continue to catch new staff or refresh old staff.
- Leaders think that a new initiative is what is needed to light the fire under staff, but this is almost always wrong. Staff fail to do something because they think it is hard, or it is stupid, or they really don’t know how to do it. But if a staff member says that they will be subject to retraining or asked to defend their statement. If, though, staff say they don’t do something because it is ‘boring’ leaders will sigh, nod, and not talk about it again. This sets up a vicious circle. A new process is rolled out, staff don’t do it, the process is jettisoned and a new process is rolled out. As mentioned, it takes time, attention and holding staff accountable to hardwire something, but if, like a lot of organizations, new things get tossed out, poorly implemented and then discarded for a new shiny thing, staff becomes less and less likely to take any of it seriously. They will realize that they can play Angry Birds during the training session and then keep their heads down for a few weeks until this, too, goes away.
Obviously, if something is not working (that is, not moving the scores), it should be evaluated. My experience, though, is that the vast majority of time, it is not moving the scores because it is not being done. A lot of blood and treasure went into signing a contract for this flavor-of-the-month, so if your hospital is eagle-eyed on the balance sheet, perhaps don’t waste the money by jumping ship until it really makes sense.
I list this as a threat to service because with heavy competition for staff attention spans, significant turnover, as well as leadership’s short fuse for results, service is increasingly treated like a magic wand that can miraculously fix things, ignoring that service is about building culture and building culture is hard work. I firmly believe that, though clinicians dismiss patient experience as ‘mints on the pillow’ they secretly wish that it was that easy. The reality is that in this environment, it ain’t that easy.
Technology Solution
Along with the constant pursuit of the new, there is an increasing belief that technology will save the day. I am not a luddite, though some (I am looking at you, Hope Brown) do accuse me of being a bit behind the times because I like physical media and my mp3 player. She even rolled her eyes at my suggestion of engaging in an email conversation when texting was just fine for her. Setting aside my rather passionate thoughts about what I want to listen to or watch being determined by the whims of platforming and deplatforming music and movies, or my distaste for typing on my phone with my big fat thumbs, I am not opposed to the use of technology when it comes to patient experience.
My problem is that, like so many things, available technology is seen as an easy fix to compliance failures. If I had a nickel for every time someone said, “I would round, if we had a rounding tool” I would have Starbucks every day. I just don’t believe it and I will tell them that. A tool won’t change compliance. OK, it might document compliance, which would in turn provide a cudgel to beat non-compliant staff into compliance, but it doesn’t move people to do the work in-and-of-itself. It may make it easier to round on seven patients instead of five, but it won’t force you to leave your office and talk to patients, if you don’t want to.4
I tend to be a demand-driven technologist. A rounding tool won’t magically make you find the time to round. It may make you more efficient at documentation, or it might make it easier to email staff of a gap that needs addressing, but it won’t inspire you into thinking rounding is important. When you show me that you are rounding and a tool can be a force-multiplier, I am certainly willing to get that technology. But too often, organizations buy new technology expecting that it will magically improve performance. PX is about building memorable experiences. Tools may make something easier to do, but they don’t make it memorable. Whiteboards are a good tool, but they are only as good as the stuff documented upon them. Even digital whiteboards are only as good as the data source that feeds them.5
Technology often gets in the way of building good service experiences. I have seen people rounding with a rounding tool who will never take their eyes off the tablet, reading questions and documenting answers with all the passion of Ben Stein in Ferris Bueller’s Day Off. Rounding tools don’t encourage conversation, as they have hard-stops and nonnegotiable questions to address. I have seen it turn good rounders into bad rounders because they focus on the minimal requirements and not the expansive conversation. They are more afraid of missing something than interested in building a connection. They feel like they need to ask every question on the screen and not find out what truly matters to the patient.
Currently, there is no technology sexier and more ill-defined than Artificial Intelligence. I am not convinced that AI will make anything better in the short-term seeing as marketers are better at slapping the letters on something than programmers are at designing a use-case for it. Right now, it is great at summarizing comments and that is useful. But saving time by summarizing comments is only useful if you, then, DO SOMETHING with those summaries. I don’t see those summaries being used for very much, except in the blame-and-shame game. “I told you that Doctor X and Nurse Y were problems for months. See? Even the patients get it!” Using AI tools to codify and clarify data is fine, but all of that is just navel-gazing, if you don’t build action plans off that information to change how patients perceive the experience.
There are those who think that it could replace some service recovery work, by creating chatbots that could intake and resolve patient complaints. I am not sure patients would respond well to this impersonal touch, and I am certainly sure that IT departments would be highly concerned about what server that data would sit on, for fear of HIPAA and PHI concerns. While usually behind the curve, the government’s current guidelines for 1557 compliance have rules about where and how AI and machine learning can be used.
In the end, this is a threat to service for what I hope is an obvious reason. Service is, in its essence, about building a connection between two people. Someone will have to explain to me how inserting technology in-between these two people will aid in building that connection. I am not saying that it cannot, but I am not sure how building impediments to communication will improve communication. Please tell me in the comments how I am wrong, if you think I am wrong.
In the end, money, boredom and a belief in a technological utopia all threaten what service will look like moving forward. Understanding how these things challenge what patient experience champions do is important to help them speak the language so they can be architects for the PX future and not leaves in the winds of change.
1I often refer to this as “Step 1: First be Mayo.” Having seen a few conference presentations from Mayo that start by assuming that you have all the infrastructure, the name recognition and the resources of Mayo. Mayo is impressive, but telling an audience that the path to success starts with a firmly developed dyad arrangement, an advantageous payor-mix, and a built-in world-wide name is not helpful to the rest of us.
2The numbers I cite here, I pulled from this article. Obviously, it is only one source, but I have heard these broad trends in other articles as well as parroted by health care experts.
3There was one article from 15 years ago that linked good patient satisfaction scores to increased health care costs more due to increased utilization and other things. I will not spend any time discussing it right now. For those curious: Fenton JJ, Jerant AF, Bertakis KD, Franks P. “The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality.” Arch Intern Med. 2012;172(5):405–411. doi:10.1001/archinternmed.2011.1662
4I know there is someone reading this saying, “Oh, I want to, I just don’t have time!” To them, I will say, someday, I will write an essay about how I don’t believe it when people say this. For the moment, I will just reference the Thor meme.
5I remember talking with nursing about why the DOCTOR box on the whiteboard was often blank and was told that it was difficult to easily ascertain the name of the patient’s doctor, especially if it was a hospitalist. Well, if the EHR doesn’t have the right doctor’s name, why would the electronic whiteboard feeding from that EHR have the right doctor’s name?
PX Matters with Joseph Snipp 
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