Patient Comments, 2 : Picking the Ripest Patient Comments

After writing an essay about how if you don’t control the narrative, it will become impossible to manage, it seems reasonable to talk about how to set a positive mythology and how to use patient comments to craft actions that will reinforce its power.  This starts with using patient feedback with intention.  Most managers share patient feedback, but too often, they do so without any context, so the positive comments are like glitter-bombs, and the negative ones are like flaming bags of poo.  They linger in the air for a moment, but then the meeting moves on and they are quickly forgotten.  If you want these comments to resonate, you need to be thoughtful about it.

Before you can craft a message, though, you need to pick the right comments.  What usually happens is that a leader is prepping for their huddle or team meeting and realizes that they need some comments to read.  So, they grab the last report, or quickly log onto the portal, and cruise for comments.  They will often look for ones that call out a specific person, and they also skim for the long comments, figuring that the more words, the more meat there is on that bone.  Neither are bad strategies generally, but both fail to identify what really makes valuable comment.  Note that I say “valuable” or “good” in describing a useful comment regardless of whether it is a positive or negative comment. 

Before we dig into specific examples of noteworthy and useless patient comments, I want to call out two broad mistakes people make as they review comments.

1. Lack of representation.  A vast majority of the comments patients make are positive.  If you are only reading negative ones at your huddle, then, you are feeding into the myth that everyone hates us, and we need to be better at being hated less.  Perhaps you think adding some sugar will help the medicine go down, so you add a positive comment with your negative comment.  But, if you read one positive comment and one negative comment, you are sending the message that we are on a razor’s edge, with half of our patients liking and half hating, which, again, is just not true.   This doesn’t mean reading nine positive comments against one negative comment to reflect reality.  It means realizing that the value of a comment is not in whether the arrow is pointing up or down, but in the actual content of the comment.  So, you should call out that the comments you are reading were purposely selected to illustrate a point.  Otherwise, staff will not focus on the message, and just see the flaming bag of poo.  “Yeah, yeah, yeah, I get it.  We suck.  Can we move on?”
2. Every deficiency demands equal attention.  Patients leave comments because they have an opportunity to.  Some surveys will ask “What can we have done better?” which drives patients to talk about the gaps in care.  Even if the survey leaves the value judgement out with a question like “Is there anything else you would like to add?” a patient may focus on any issues that were not covered in the survey.  But every comment does not weigh the same.  There are three things that determine the relative importance to every comment made.
   1. The comment itself.  There are some comments that mean more within the care experience than others.  A comment about the communication and alignment between provider and lab tech is more important than a comment about the comfort of the chairs in the waiting room.  I am not saying that comfort is NOT important, any more than I am saying that the volume on the waiting room TV, or cigarette butts in the parking lot are not important.  They are, but likely not the responsibility or focus on the clinicians that you are addressing.  The only thing the clinicians can do about chairs and TVs is to bust their butts to prevent people from having to sit in the waiting room very long.  By reading a comment about a nice nurse and an uncomfortable chair, your team will imagine that these are equally important to you.  *Spoiler alert* they should NOT be equally important to you.
   1. The number of comments.  The longer comments are the ones your eye is drawn to, and these often are laundry lists of issues the patient sees.  These comments are attractive because they are a one-stop-shop for a negative comment to read.  These comments feel meaty because there is a lot to process, but in reality, when you read these to staff, their eyes glaze over.  There is so much in there that it ceases to be useful feedback.  While there may be a nugget of wisdom in there, it can be hard to spot.  This is especially the case, since once the staff hear an element in that list that they cannot control (like “the exam room was too bright”) they will dismiss the entire litany as stupid, silly or outside of their control.  Oddly, the more you throw at the wall, the less that sticks.  On the other hand, a shorter comment focused on one issue is likely more meaningful to the patient¹, so it should be more meaningful to you.
   1. The person who made the comment.  One thing that people rarely do is look at who made the comment.  Not the actual person, but what that person gave for your benchmarked question.  A patient who gave you your desired top-box response may have things to say, but all criticisms should be taken as “nice to have” rather than “must have” since the person giving the response is already a fan.  Less obviously, if a patient gives you a bottom-box response and says negative things, these are also not helpful.  There may be useful comments in there, but since this person is not likely to be converted to top-box any time soon, they likely speak more about their general discontent than any specific actionable deficits.   Concrete suggestions made by the people in the second-box should be your primary focus.  These are folks who are telling you what likely kept them out of the top-box.  Addressing them are more likely to help boost your overall score.²

Again, you may take issue with me prioritizing comments, and say that I am saying some patients are less important than others.  This is not what I am saying.  All patients are important.  Time and treasure, though, are limited, so treating all comments as equally valuable means that you are not budgeting your resources to address the important or low-hanging opportunities effectively.  If there are specific comments that end with, “…and I am calling my lawyer” they should immediately be logged in your complaints portal.  But to motivate staff, it cannot be about one-off experiences.  Building a useful mythology starts with identifying important trends.

To pick the right comments, it is helpful to bucket the comments against three dimensions:

• positive/negative: did we do something right or wrong?
• broad/specific: is the comment about a vague sentiment or call out a clear behavior?
• general/personal: does it paint with a broad brush or identify a specific person or department?

You don’t need to literally bucket each and every comment, but as you are reading comments consider this classification as it will help you identify useful ones.  Some vendors will also classify comments as ‘neutral,’ but outside of the non sequitur comments, if a patient mentions it, it is important to them.  (Though again, not necessarily important to you.)  If the comment isn’t obviously positive, then it is probably negative.  (Again, more on that in another essay.)

So let us look at the four types of comments and their relative value.  As you will see, these are mostly spectrums, where a comment can be more or less positive or specific than another one. 

Broad/General.  These are the comments that do not call out any specific behaviors or specific individuals but reference an overall sentiment or feeling.

• “Everyone was nice”
• “I love them!”
• “They don’t know what they are doing!”
• “They suck.”

These are the glitter-bombs and the flaming bags.  These comments have no value, since they don’t tell you WHY you were awesome or horrible.  They are empty calories.  They don’t even translate well to reading out loud or posting in the break room, as they have no substance.  You can use them to create percentages of positive or negative comments or feed them into a word cloud, but otherwise they are fly-over comments.

Specific/General.  These comments are still globally focused but bring some broadly actionable detail to the equation. 

• “The lab staff are so fast”
• “This infusion center is professional”
• “Everyone at the clinic seems flustered”
• “I cannot believe how rude everyone is.  They are supposed to be taking care of people.”

Here, we are starting to see more substance and this substance points to useful conversations.  You can talk to your team about what “professional” looks like, or what process changes have allowed you to be “fast.”  You want to avoid, though, taking the comments at face value.  Words like “flustered,” and “rude” are loaded and if not handled delicately in conversation, there will elicit responses of “We were not!” and the conversation will spiral.  You can use these comments, but you must guide the conversation.  Read the comment, but then follow it with a “why do you think a patient thought we were flustered?” or “are there things that happen that knock us off balance and can make us appear flustered?”  Notice that these questions do one very important thing.  You are implying that this is a patient’s opinion and not objective fact.  You are not saying that the team is flustered; you are asking them to put on the patient’s shoes and consider why the patient perceived the team as flustered.³ You are working with them to understand where that perception came from so the team can correct it and show their patients who they really are.  Here, you could do a one good/one bad comment for a compare/contrast conversation: This person said we are friendly and this person found us gruff.  Why?

Broad/Personal.  These comments single out a specific person or department, but only provide a general positive or negative comment.

• “I go to the lab every week and I love getting Denise; she is the best!”
• “Nurse Y is a such a sweetheart.”
• “I can’t understand Doctor X.”
• “The financial services people are so rude.”

This is the siren’s song of patient comments.  You think that these are useful or telling, but often they don’t connect with your audience.  Too often, they generate defensiveness or disregard from the audience.  Since they are not specific, they are seen as supporting a myth regarding the person/department or the universe of patients.  At best, they are simply dismissed with an “everyone says that” reply.  At worst, they devolve into he said/she said (or more accurately patient said/doctor said) scenarios, since one person’s ‘rude’ can be another person’s ‘professional.’  Further, because they are vague, they get filled with subtext from the audience.  Do patients fail to understand Doctor X because of his accent, because of his use of jargon, or because he doesn’t give clear, definitive, answers?   Notice that the broad comment can be used to feed a myth without noticing or caring about the patient’s intent.  Even the positive comments, like those about Denise, are often discounted because it is just about Denise and we all love Denise, but we cannot all be Denise. 

Specific/Personal.  These are comments that identify a specific person or group and give more detail as to what makes them noteworthy.

• “The receptionists at the clinic are all so friendly and welcome me every time!”
• “It means a lot that Doctor X asks about my father who has cancer.  He seems really concerned about the stress I am facing.”
• “The doctor seemed to be reading my medical record for the first time.”
• “The nurse made a ‘tsk’ sound when she read my weight.  I really am trying!”

These are the holy grail of comments because they are the most substantive.  If you are going for sheer length, these generally win, because the thing that makes them longer (some amount of specificity) is also what makes them valuable.  But even with these, you need to position them within your needed context because they can still generate a patient said/doctor said scenario.  But, placed within a context, these comments have their own built-in action plans since the patient is identifying exactly what they are responding to.  One may not know how to action-plan “be friendly” but one can certainly action-plan “welcome every patient to the clinic.” 

Context is critical here as well, since different patients in different situations may respond to different things differently.  The comment about the doctor appearing to read the medical record for the first time came at a primary care clinic staffed by residents on rotation and the patients were largely on Medicaid with no long-term primary care provider.  So, in a normal setting a doctor reviewing a chart while talking to a patient may not seem that outrageous.  Here, though, a patient may feel defensive about the fact that they are on public health coverage and feel like they have to attend this clinic with a revolving door of doctors.  They may, therefore, be more sensitive to behaviors that they feel marginalize them.

There is a lot more to say about using patient comments to sculpt a useful action plan, but for the moment…  Start by not picking crappy comments.  Make sure the comments you read contain a context that you can leverage into behavior change.  Don’t read comments simply to fulfill a quota on your way to the next agenda item.  If you treat them as wallpaper, they are just a bit of throwaway piffle.  If you do this thoughtfully, they will motivate staff better than a thousand bar graphs.

¹These are meaningful because they were called out in isolation.  Of all the things they could have talked about this one thing was the one that felt worthy to address—good or bad.  The long lists sometimes feel like a snowball rolling down a hill.  As it picks up momentum, it also becomes unmanageable and unfocused.  Always exceptions to these rules, but you want your team to be focused on a single message and that is hard to do if you give them seven things to think about in one comment.

2Once you read your second-box comments, you will come back and say that they are mostly positive and often vague, so how to I action plan around them?  That is an excellent question that deserves its own essay.

3Personal confession here.  I have had people say some version of “Joe can be rude when you first meet him but is really a great guy.”  I did not like that people found me ‘rude’ so I investigated and discovered that I suffer from RBF (or resting bitch face for those not familiar with the abbreviation.)  So, when people stop by my office and I would look up from whatever I was doing, my face was not welcoming; I looked vaguely annoyed at the interruption.  I set out to be more aware of this first impression and was able to change that perception to “Joe is always really busy, but will always make you a priority.”  There ends the humblebrag.