I got an email from a friend last week wanting my thoughts on what to do with PX during her hospital system’s reorganization. Since she also said nice things about me and these essays, I wrote her an answer to her question but then thought it was a topic ripe for an essay. OK, in my world, two essays…
In previous essays, I wrote about how the Patient Experience department can end up being the junk drawer for anything that seems patient-facing but has no clear home. Volunteer Services? Give it to PX. Gift Shop? Give it to PX. Training? Give it to Organizational Learning and Development. Oh, you mean PX Training? Give it to PX. Data questions? Give it to Business Intelligence, unless—you guessed it—it is PX data questions. This is not your garden variety whining about how no one understands what we do. It is the simple statement that for an organization whose primary purpose is to keep people alive with multi-million-dollar pieces of equipment and highly trained staff members, figuring out how to pigeonhole a department that neither administrators nor clinical staff fully understand is challenging. Plus, outside of HCAHPS and other survey scores, there are precious few measures that one can use for efficiency or benchmarking purposes. While the PX budget might run a couple of million dollars (mostly for survey execution), this is still barely a rounding error for a hospital system’s overall operating budget. Meanwhile the PX staff are not necessarily well-trained on how the dance the corporate dance and help define what is in-scope and out-of-scope. As a result, when you have seen one hospital system’s org chart for PX, you have seen one hospital system’s org chart for PX.
How a hospital/system structures their PX says a lot about how that organization views patient experience. Odds are that you don’t work in a hospital that treats service exactly how they treat other key elements in their structure. So, while a hospital may structure their finance as:
Chief Financial OfficeràSenior Vice PresidentàBunch of Vice Presidentsàeveryone else
Most hospitals do not have a Chief Experience Officer or CXO. Many don’t even have a Senior Vice President in charge of patient experience exclusively. In short, most (yeah, I said ‘most’ and not ‘many’, prove me wrong) systems do not have their service section follow the same broad organizational structure that the other key non-clinical departments have. This does not mean that they have broken or dysfunctional PX departments. Only that, for a host of reasons, their PX vision has not evolved to the same place that their other departments have evolved to.
It would be easy to say that the PX structure should be a photocopy of the other departments’ organizational structure. Not necessarily in size or complexity, but in its overall form. But, as you will see, in my opinion that answer is too simplistic and certainly is not realistic in a Day 1 reorganization. Instead, I am interested in exploring how hospitals do structure their patient experience work and what that structure says about their PX strengths and weaknesses.
All organizations are savvy enough to pay lip-service to patient experience. If asked, a CEO or President will say that the hospital stays open based upon the satisfaction of their patient population. But when you poke at this verbal commitment, a system’s real commitment to patient experience is hazy. One key reason is because what patient experience looks like is also hazy. How senior leaders can affect PX is also hazy.
This starts with one simple question: who owns patient experience in your organization? An organization that does not have a very good sense of PX is or is supposed to be will give the platitude, “Patient experience is really everybody’s responsibility.” This answer feels right but starts to crumble under any bit of scrutiny.
It is true in the abstract. Just as it is true to say that proper fiscal stewardship is everyone’s responsibility. Best-case clinical outcomes are everyone’s responsibility. Everything is everyone’s responsibility. But leaders only rarely might use the phrase in those contexts. Why then does PX get this special designation? Because the unspoken follow-up is that, since PX is everyone’s responsibility, we don’t need a concrete structure surrounding it. One would never say this about clinical care or balance sheets. A CFO would get fired if they said, “Since fiscal responsibility is everyone’s job, we really don’t need a finance team.” Now, I have never heard anyone directly say this about PX either. This is, though mostly likely because they know that they should care, so they know they shouldn’t say that, even though, maybe they kinda do think that. The problem with many organizations is that they don’t know how to care about PX and don’t feel comfortable admitting that. Perhaps my book title should be “Everything You Wanted to Know About PX, But Were Afraid to Ask.”
Hospitals (like many businesses) rely on external voices to tell them if they are doing a good job. There are bond rating companies, banks and creditors who will evaluate the hospital system’s balance sheet. There is an alphabet soup of federal and state agencies that care desperately about the clinical outcomes. But there are no external bodies scrutinizing patient experience like there are for these other areas. One could say that hospital-compare or care-compare1 websites or the Value Based Purchasing (VBP) calculation provides external oversight. In theory, these both could provide external validation, except that:
- While research varies on what percentage of patients use the internet to make decisions about healthcare,
- I have heard people reference reviews read on Google or Yelp, I have never heard of anyone referencing the Medicare website in their decision-making about doctors or hospitals.
- Every hospital that I have worked with has a laser-focus on negative Google or Yelp reviews, but no hospital I have ever worked with has spent more than seventeen seconds discussing the grades they have received by CMS. It has never occupied more than one slide in a fifty-slide deck presented to leadership on overall CMS performance. I have never heard anyone ask a single question about a hospital’s star rating on the CMS website but have heard countless hours on how to identify and address star reviews left on more well-known websites.
- Value-based purchasing contains a wealth of data smashed together to create a single overall score. When there is conversation about VBP at a hospital, it generally focuses on the clinical elements rather than the question domains on the HCAHPS survey. Since the VBP score is a single number, it is difficult to identify how PX influenced the overall score.
- When considering the cash at risk and the percentage of money that is affected, it doesn’t amount to much on the balance sheet. I once had a CEO say that the amount of money at play was ‘tongue-depressor money’ saying that the organization spent more on tongue-depressors last year than was at stake with VBP.
So, whether it is choice or acceptance, one dirty secret about hospitals is that they mostly care about how the agencies that can hurt them view them. If you are an agency that can make life difficult for them, you will get far more blood and treasure dedicated to your needs. Please don’t mistake this sentiment as a statement that hospitals don’t care about patients. They absolutely do. They care about providing the best care for their community. But like any organism, they respond to the most dramatic stimuli first. There is only one patient survey (HCAHPS) that even marginally matters in this regard. HCAHPS has, at best, a muted impact on a hospital’s day-to-day operation and it pales in comparison to sentinel events and Days Cash on Hand calculations. Other surveys in the CAHPS universe mostly give credit for playing rather than in performing well. Yes, I know that my friends in post-acute care will say that the home-health and hospice surveys matter at least a bit. But even there, where the margins are so thin they make razors look blunt in comparison, most organizations are far more concerned with labor costs than likelihood-to-recommend scores. The primary conversation I have had with post-acute care is how they can satisfy their need for CAHPS surveying for as little money as possible.
Compounded with this, most organizations don’t know HOW to affect the patient experience. PX has outcomes measures, which is how organizations can justify service on the pillar. But far less clear is what in PX can be used as a key performance indicator or a leading-measure. Nation-wide, the broad job description varies significantly. I have discussed in previous essays, whether an organization starts with an FTE and then back-fills with other “responsibilities as assigned” or if they dial-back on the FTE to conform to the narrow work definition, there are no good national benchmarks for what productivity looks like.
I once created a calculation on what PX staffing should look like at a multi-hospital system. I created a simple algebraic calculation, creating coefficients for variables like:
- Total inpatient discharges
- Total emergency department discharges
- Total clinic discharges
- Total clinics on-site vs. in medical office buildings vs. stand-alone
- Total footprint of clinics (to account for windshield time)
- Total number of logged complaints and grievances
I made the measure FTE-neutral by fitting it to the current FTE counts. I wanted to do two things with the measure. First, I wanted to see if the resources matched the resource needs. Since the PX staff were assigned to specific buildings, I wanted to see if this designation allowed for the best most equitable work distribution. Second, I wanted to create a baseline, so as the organization grew in patient volume and in number of facilities, one could evaluate the current staffing relative to past staffing. In essence I wanted to create efficiency metrics where none existed before.
When I presented the data, I was surprised by two things. First, I realized that I was in a room of leaders that had zero idea what their PX team was doing, They did not realize the amount of data and reports they were managing, the number and variety of complaints they were resolving, nor did they see the demands that covering the expanse of their footprint meant. Second, given how little they knew about their team’s work, I was impressed with how quickly they became modeling experts. The results showed that even when we kept the FTE-count the same, the actual distribution of those FTE based upon criteria was radically different from current-state. So, to justify their staffing (or lack of staffing), they proposed a remarkable array of nonlinear variable suggestions. They wanted variables that climbed, leveled off and then climbed some more. They wanted lines that asymptotically approached either zero or some fictional maximum number of possible patients. Even after I explained that, in keeping this FTE-neutral, none of their suggestions would alter the overall distribution, they still maintained that this could not be right. I even had one leader pull me aside and insist that their campus should be the baseline and all other projections should be made by setting their building at the perfect 1.0 FTE.
None of these conversations were based upon anything other than their desire to (a) be seen as fiscally responsible, and (b) not let a single FTE slip through their fingers. While I can certainly relate to both desires, it also illustrated that these leaders had no idea how to evaluate their own talent. They were thirsty for some efficiency metrics but were also skittish about using those measures against what they saw when they turned the lights on.
So, organizations could not establish appropriate staffing and standards by the sticks and carrots distributed by external evaluators. They also could not agree what internal metrics should look like. So, it is no wonder that organizations flail about when trying to figure out the broad confines of PX work and staffing. In my humble opinion, this is often why organizations want to insert this work under an existing structure. That structure, be it Marketing, Quality, Clinical Care or some other department has readymade metrics, and the hope is that somewhere in there a leader will find footing to create structure. Of course, in that process, they also change how PX is defined and what PX departments are tasked to do. But that will be the topic for the second essay.
1The actual website is (https://www.medicare.gov/care-compare/) and hasn’t been hospital compare for quite some time. Still it is easier to reference the CMS rankings of hospitals as hospital- or care-compare, rather than medicare.gov-slash-care-compare.
PX Matters with Joseph Snipp 
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