In the last essay, I explored that the way some hospital employees approach service is driven by zero-sum thinking. In the essay, I focused on big-ticket issues created by this tension, but this mindset poses challenges in more traditional daily interactions. If staff see hourly rounding or informing a patient about being a fall-risk as zero-sum, they are less likely to do it. In fact, if you hear a staff member say something like, “It doesn’t matter if I explain something; they don’t listen to me or remember what I said” then that staff member is really saying that service is a negative-sum game, where service initiatives makes work for them and the patients derive no benefit from it. Not only does this mindset make it difficult to train service (since they define service as “more work”), but it also often leads to negative-sum outcomes simply because staff find their jobs harder because patients feel poorly served and make more ad hoc demands. This, then, feels the vicious cycle, where patient ad hoc requests lead to less opportunity to execute the initiative, which leads to even more ad hoc requests.
Since service is meant to show care and attention when things are good and understanding and compassion when things go sideways, it is not surprising that failing to deliver on it can make life more difficult for all involved. In this essay, I will explore ways that people who train patient experience work can short-circuit that thought process and address these impediments so service training can focus on positive-sum outcomes.
Understand your audience
Call me naïve, but as a young adult, I just assumed that some careers—like a teacher, a nurse or a doctor—were callings or vocations and not jobs. People did them less for the paycheck and more for the ability to serve a community. Working in education for a couple decades broke me of the first misunderstanding, but it took me longer than I will admit to learn that people in healthcare may not all be altruistic folks who get satisfaction by helping and caring for people. I got my reality-check about twenty years ago, when I asked a nurse why she was a nurse. Her response was that she hated her retail job and so she stopped at the local technical school that she drove by every day and applied for the nursing program. The reason she selected nursing was simply because the application window for the metalworking track was closed. Since then, I have realized that for some healthcare as a career with more pay and better growth potential than other available jobs. It is not that they aren’t interested in helping people, but they did not come to this work because of a calling. To be clear, this is not meant as an insult or judgement. It is not a bad thing. Heck, my path to where I am was circuitous and only recently would I call it a calling. It may have been better than other options, satisfying in-itself, and I had an aptitude for it, but my passion came later.
This is important because understanding the motivation of your audience is crucial to motivating your audience. Talking about culture, or reading moving comments or touching letters may not move an audience to pay attention. Given that this is often a ploy to connect with this crowd, in a training session or a huddle, you using this approach won’t be novel and may generate eye-rolls from some. Increasingly, my training starts with two key messages. First, I will focus on the distance between where we are and where we would like to be. When audiences see that 90% of all patients are giving the organization an 8, 9 or 10 and our desire is to move 8s to 9s, they understand that I am not looking to move a mountain, but build consistency around small but significant things. Second, while I will talk about patient benefits, I focus on how doing the things will make the staff’s lives easier. So hourly rounding means reducing the number and burden of call-light responses. Being thoughtful with introductions and explanations means having fewer random ad hoc questions, so it takes less time to explain something from beginning to end, than to start in the middle, go backwards and forwards, and then summarize it all.
Some may be saddened by the fact that my approach doesn’t speak to the higher calling of healthcare or the joy associated with the work. While I will use stories and patient comments at times, I have found that many in the audience simply want to know the WHAT and WHY of the training and the so-called rah-rah stuff gets in the way. I find it better to use anecdotes to illustrate training points, rather than use them to motivate interest in the training itself.
Don’t fall into the zero-sum trap
You might wonder how, if I am avoiding the emotional stories and instead focusing on self-interest while stressing the small but significant things, how I am not simply reinforcing the zero-sum perspective. After all, if I am focusing on the value to the clinician, doesn’t that encourage a focus on the ‘costs’ that the clinician is making to harvest ‘benefits’ for the patients? I will acknowledge that this is a delicate balance and my solutions are not foolproof. There are, through, a few things you can do to improve your chances of staying out of this trap.
- Avoid global always/never statements and stereotypes. If you play into ideas like “ED patients are drug-seekers” or “new moms are hyper-critical” or “old people hate technology”, you end up dehumanizing the patients and turning them into a trope. By saying that those patients are different, it becomes very easy to define the work you do to address their questions or concerns as “extra” or “an undue burden” to the work you “usually do.”
- Focus on what you can control. Part of this trap is driven by the belief that others are demanding something special of the staff or making their work harder. This is often displayed in cross-departmental complaints. These usually start with staff saying something like “You should talk to the guys in…” before they complain about how the ED nurses, the floor nurses, the imaging folks, the transpo crew, the scheduling team, or the billing department makes their life difficult. Just as you cannot control patient expectations, you cannot control other departments’ workflow. So instead of cursing others, look in a mirror and ask how you can make your work life easier. Remember that most of service is setting expectations and addressing gaps in process. Waiting until everyone else fixes their deficiencies before you work on yours has an obvious outcome. You know, since at the same time, everyone else is waiting for you to fix your problems before they fix theirs.
Get on the same side of the table
When I have meetings with folks and it is logistically possible, I aways sit on the same side of the table as they do. I feel like when I sit on the same side, it feels less confrontational than when we sit with a giant conference table between us. Maybe it is just my perception, but it feels like things are more convivial. Plus, if you are literally sketching something out on a piece of paper, you are both facing it from the same perspective.
By extension, if I am meeting someone one-on-one in an office, I would rather be in their office than mine. I want the person I am talking with to be comfortable. Making someone stop their workflow to come to my office to meet feels needlessly stressful for them. Though I don’t think I am a stressful person to work with, they may not know this, so they often arrive with their defenses raised. Further, if I come to them, I am showing them respect and demonstrating that I want to work with them and not be unduly burdensome.
I also use this concept metaphorically when training. Too often training feels like a judgement on performance. I am here because you guys suck with something. With that dynamic, often the audience will tell you the dozen ways why what you are asking them to do won’t work. Then you fall into a playground fight of no-way/yes-way until time and patience is exhausted. I start with the message of “You are already doing this but let us think about how to build consistency or add a little cherry on top” rather than, “Here is new stuff you need to learn and do.” Some will say that sometimes you ARE training something NEW and they DO need to stop sucking at it, but I disagree. There is nothing I have trained that doesn’t have SOME sort of connection to work they are already doing. By acknowledging that they are already doing what you want and you are there simply to help iron out the wrinkles, or problem-solve the obstacles, you get them to see themselves as the solution and not the obstacle. You are not lecturing, you are learning along with them. Plus, by relating this training to work they are already doing, you get to pull them into the conversation by asking “What sort of response do you get from the patient when you do this?” or “You said that you used to do this, so I am curious, what happened that made you stop doing it?” All of this builds up the collegiality needed to help move this new work to old habit.
Focus on consequences
This approach is especially critical if the topic IS one of conflict. I wrote last time about red-flags in the EHR. I think that these things are counter-productive, especially when they are not visible to the patient and have no organizational oversight. When I was working with a friend and her conflict with Employee Health over these, I told her that she would not win in a full-frontal confrontation over the practice. Further, she would develop a reputation for being seen as anti-staff-safety.
Instead, I suggested that she focus on the undesired or unexpected outcomes of this policy to tweak it so it would be truly successful. So, we identified some problematic downstream impacts and helped build solutions to those. This also allowed her to address the “don’t bring me problems without bringing me solutions” mentality that many leaders express. She identified the three things she thought were counterproductive to this policy and then created the first-draft for solutions.
Problem: No end-date for red flags, meaning both that a patient could be haunted for a lifetime over one bad day and an EHR could become clogged with outdated flags and therefore ignored.
Solution: Create a sunset for red flags, where, unless you are a repeat offender, it drops off your record after some established time period, like for example, three years.
Problem: No oversight means any staff can attach a flag for any reason. This can lead to inconsistent execution and can become a reason why staff disregard flags they consider trivial.
Solution: Create oversight, where all flags are reviewed by a third party using a set standard or rules. This consistency will allow clinicians to take them more seriously.
Problem: The current process does not notify a patient of the flag, meaning they have no opportunity to address, respond to, or even acknowledge the incident. This “secret double-probation” can lead to patient distrust, especially if the patient learns of this status much later from a second-hand source.
Solution: Provide for patient notification of the red flag after the fact (to avoid escalation in the moment) including information on consequences for the red flag as well as next steps on how to appeal or remove the designation.
Notice that this work can fit within a traditional SBAR and if focused on guiding the conversation to a constructive solution rather than being a straight-on fight that is guaranteed to generate more heat than light.
This approach is valuable not just in addressing significant policies or processes, but also in more immediate training ways. Often the trainer doesn’t need to provide downstream examples but only connect the dots. I was talking with an emergency department doctor who was complaining about a review a patient posted to Google. She was upset, saying, “Well, if they would have said this to me directly, I could have addressed it and it wouldn’t be on-line.” I agreed with her and we discussed what warning signs she could have noticed to allow her to address this in the moment. We then moved on to how the communication workflow she was trained in would have prevented this outcome. She then acknowledged that if she were more diligent in executing it, she would not have this review on Google. We then were able to talk about what she would need to build consistency in this process. So, I didn’t need to explain why this communication was valuable; I only needed to help her cross the stream by hopping from stone to stone.
Not only can you connect the training with avoiding negative consequences, you can also create a built-in measure for evaluating the training’s effectiveness. For example, if hourly rounding reduces call-lights, one can simply pull call-light usage from the electronic health record and determine if consistent rounding produced the promised value. This either becomes proof of concept or highlights a need for further exploration to understand why the rounding is not reducing call-light frequency. Either way, you are showing your audience that you are interested in understanding their reality. You are not simply trying to sell them a process, but you want to be a partner with them to produce value.
My experience is that staff want to be better and do better work. By meeting them where they are, both figuratively and literally, you are showing them that they are not the enemy or the problem and neither are the patients. Consistent work on the small but significant things can make their job easier and their patients’ experiences better.
PX Matters with Joseph Snipp 
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