In the last essay, I discussed how hospitals struggle to figure out where to put PX in their organizational structure. Again, this was less of a “woe is me” sentiment, so much as an exploration of why PX seems to not fit neatly in a traditional hospital organizational structure. PX is no different from a lot of departments that have impacts and relationships with other departments and areas.1 But unlike a lot of similar departments, PX often has a presence on the pillar, and its impact is obviously visible to senior leaders. This reality means that by not giving PX a similar structure to other pillar elements it cannot be expected to behave like other pillar elements. For example, by not giving it the same set of leading indicators or performance indicators, it cannot be held accountable in the same way as other elements in an org chart. This often means that organizations will put OX somewhere in the org chart that does have the consistent structure and measures, with an expectation (or hope) that by osmosis, it will naturally conform to the organizational norm.
In this essay, I want to explore where businesses usually store PX and discuss what impact these choices have on what PX prioritizes and how it functions. This is not about classifying these decisions as awesome or suboptimal. It is about helping people identify what limitations these decisions create, so that they can either acknowledge them, or, set about to prevent these limitations from impeding the work that PX does. In fact, I would argue that there is no perfect solution, so much as making sure that the fit selected is managed effectively. My point here is to review the four most common locations for PX to live in and discuss why each is seen as a good fit, how it is a good fit, and how this location can lead to issues when defining PX’s book of work. The four popular locations are: marketing, clinical care, quality, and on an island.
Marketing/Communications
Back in the 1990s, PX was often housed under Marketing in some capacity. This was likely because it was seen as an element of a hospital’s reputation in the community. By the 2000s, the pendulum swung away from Marketing, mostly because HCAHPS arrived and changed the focus for many organizations and because PX itself started to develop several other responsibilities that did not align with marketing. These included service recovery work, service training, PFACs, and ownership of other patient-facing elements, like valet services and the volunteer team. Of late, with a focus on the fragmentation and increased competition in certain areas of patient experience, the pendulum seems to be swinging back.
Upside
The care model has changed, with more work going on at the clinic and outpatient services/surgery settings. This has drawn more attention on this competitive part of the market, often with the off-putting and cringey terms of “leakage” and “keepage” becoming popular. On paper, at least, Marketing seems better prepared to construct a consumer model that can compete in that environment. At least better prepared than other departments in the hospital.
Further, of all the potential homes for PX, marketing understands how service can improve community perceptions. While I personally roll my eyes of them coopting terms like “guests” and “customers” from traditional service work, they do better understand the through-line from positive experiences to positive community perception.
Downside
There is probably no department in a hospital less-connected with the actual work of the hospital than Marketing. They may work with specific clinics like pediatrics or plastics to generate outreach strategies, but they often don’t know how those specialties function in delivering their services. They often don’t know much about how hospitals work and how these dynamics can lead to challenges in creating a patient experience culture. In my experience, they are great when a labor dispute with the nurses’ union or a battle over contract pricing with an insurance company goes public. But they don’t have the structure to manage the day-to-day messaging or auditing of daily service must-haves.
Further, in my experience, Marketing is adept at always telling the community the hospital’s story. They can be great talking about the humble beginnings of a small hospital created by the sheer will of a single person’s vision to the large medical center servicing hundreds of zip codes that you see today. But patient experience is primarily getting and understanding the patient’s story. Advertising is often great at telling me what I need, but it stinks at asking me what I want. Giving PX to marketing means running the risk of shutting down the one main way patients have available to tell us about their needs without interruption or qualification. In my experience in starting, running, or helping to run PFACs, for example, the one group most interested in them is Marketing. But they are the ones I am most concerned about, since often they want to turn a PFAC into a focus group. PFACs are not about road-testing advertising messages, they are about getting the patient’s perspective on how we can close gaps in how we deliver care. While there is certainly overlap there, too often Marketing is more interested in the tail and not the dog.
Clinical Care
Another popular place to put PX is under the attention of the clinical care team, mostly the nursing team. While the percentage of systems storing PX here was consistent, it seems that this may have fallen off a bit after the pandemic. Since HCAHPS’ arrival with its focus on the behavior of clinical team members in the inpatient setting, organizations see putting PX under here as shortening the distance between the clinical cause and the survey results effect. I have seen some organizations go so far as to staff the PX crew exclusively with nurses and making that a prerequisite for all PX jobs. This firmly aligns the work with the most important person associated with inpatient care, but it also can limit the reach of this message to both doctors and non-clinical personnel as well as those in other care spaces, like the emergency department or outpatient procedures. Plus, if the current nursing shortage continues, this model must confront how to maintain a clinical messenger when there is great incentive to put that person at the bedside.
Upside
Much of PX work is trying to get front-line staff to do what you want them to do consistently. As I am fond of saying, PX is about executing every time with every employee and every patient. It makes sense that if you care about HCAHPS, then getting the people primarily responsible for explanations, caring, listening, call-light response, discharge instructions, etc., to lead the charge in this space. Since there is some truth to the belief that clinicians will only listen to clinicians 3, having a nurse explain to nurses why it is important to do hourly-rounding or bedside shift reports can be useful. Further, since the PX folks with clinical backgrounds are most familiar with the obstacles that prevent execution of the PX work, they can also be best at problem-solving solutions.
Downside
There are two issues with housing PX within the clinical walls. First is that patient experience is more than just about clinical care. We can discuss (and I did in one of the early essays), the relative importance of non-clinical interactions in a patient’s experience against the clinical staff’s impact on PX. But no one would say that experiences with food service, security, housekeeping, scheduling, registration, volunteer services, pastoral care, facilities management, valet parking, to name a few, are unimportant. Yet, these audiences are often ignored or marginalized when clinical teams lead the charge. Further, with more care existing outside of the hospital, the hospital clinical staff are generally underprepared to address concerns and conditions in those spaces. In many situations, those clinical teams have their own org-chart that isn’t connected to the hospital-based care team. Historically speaking, the places where PX lives under the clinical umbrella are also places where PX will have virtually no interaction with the clinics. When I would spend a week at a hospital system where PX was housed under clinical care, I would often have a similar schedule. Every day, I would go to one of their hospitals and spend a full day there, doing presentations, talking with leaders and rounding on staff. Then on my final day (that would usually end with me violating posted speed limits in an effort to get to the airport and catch the last plane out of Dodge), I might spend a half-day with all the clinics, where they would have to travel to see me, usually at one of the hospitals. Attendance and interest, as you might expect, are often thin.
The second challenge in storing PX in the clinical space is an issue of loyalty. One can clearly understand that a nurse can talk to another nurse with empathy over the challenges of executing hourly rounds. But if that nurse also has some portion of their FTE associated with clinical care (either pulling shifts at the bedside, or as an active manager of nurses), it is also easy for them to soft-pedal or mitigate the impact of PX initiatives. On the other hand, if that nurse has interests in a life outside of clinical care, they can be tone-deaf to the questions and concerns they get from fellow nurses over consistent execution.
- Either they “go native” where they prioritize the interests, needs, and perspectives of the nursing unit over the system expectations for consistent execution of PX initiatives. So, you hear things like, “I know you are already stressed, stretched, and can’t get your real work done, but the brass wants us to do this other thing. So, you know, try your best…”
- Or they use PX as a tool to exert power over the team. They approach their work by demanding compliance and writing up those who don’t act accordingly. I have heard the PX-contact on nursing floors called “Internal Affairs” implying that, like the bastardized version seen in every cop show on TV, these nurses are just there to make life difficult for the hard-working nurses who are just trying to do their job.
Quality/Risk
In an effort to move PX closer to clinical work, but not give it to the clinical team, organizations might give it over to their Quality department. This attempts to realize the value of having clinical experience in PX while providing the separation needed to address PX issues with other audiences, since these departments generally have a staff with a mix of backgrounds. Quality/Risk is tasked with understanding why events had negative outcomes, so putting them in charge of overseeing complaints and grievances also seems like an easy fit. Since Quality/Risk are experts on tracking clinical best-practices, they are comfortable measuring whether events conform to industry standards. The best teams are also talented at creating useful measures that can be used as leading indicators to those external standards. However, they also are the go-to team to perform reviews over sentinel events and determine the cause of went wrong, so they also can carry the reputation of being a hospital’s “Internal Affairs.”
Upside
Being close to, but distinct from, clinical quality, they can have the ability to both be empathetic with and demanding of the clinical staff. Since many have clinical degrees, these folks can more successfully bring PX issues into clinical conversations. Since Risk, especially, has skills dealing with when shit meets fan, they can also be very helpful in the universe of complaints and grievances.
Downside
While they have strength in navigating the negative outcomes, they may have less strength in the what-went-right environment. A vast majority of clinical encounters have positive outcomes, or at least as positive-as-possible outcomes. Quality/Risk is less comfortable when things go right, especially when people are still upset.
OK, that might not be fair. This department is the most metric-forward group in the hospital, since every patient problem carries with it a clear set of best-practice measurable behaviors. Whether it is time-to-CT, or cadence of serial troponin tests, or the sepsis bundles, Quality is keenly focused on a hospital’s performance on these metrics. So, they do know what “going right” looks like. They are focused on key behaviors that will minimize adverse events. Their gap, then, is that their focus is primarily on the WHAT and not on the HOW.
For example, Quality is focused on eliminating antibiotic use for viral rhinitis or the common cold. Quality measures primary care provider’s behavior in this setting. But one of the reasons doctors give for prescribing antibiotics when not necessary is that they are sick of fighting with parents who demand certain interventions regardless of whether they are useful. It is not that the doctor doesn’t understand what the measure is, or they think the intervention will be successful. They often lack the skills, temperament or patience to communicate effectively with patients (mostly parents of patients) who challenge their plan of care. In these situations, Quality is often more stick than carrot. So, helping staff use words-that-work to manage-up a situation is not necessarily one of their strengths. Helping staff see that the non-verbal elements (the tone, or sigh or eye-roll) associated with patient communication are often more important than the message itself. Putting PX here may be helpful with one side of their work (complaints) but it may be at the cost of their other side of work, namely building excellent experiences.
On an Island
So, one common theme in the previous three scenarios is that in some way, an organization will contort what PX is when they shoehorn it into an existing department. So, you might think that my preferred solution is that they are given their own space to flourish. While in a broad sense, you would be right, it is also more complicated and there are still pitfalls. I do think that PX works best when it is given its space to develop relationships with each of the above departments as well as with other departments, such as scheduling, finance, and food service. Of course, here, the open-world format can be intimidating, and it can make it difficult to set priorities. Putting PX in the hands of people who are trained in patient experience seems like a no-brainer. Just as I would hire accountants who know how to do accounting, in this space, you can hire PX-experts (or PXperts), to run various PX initiatives. Of course, the challenge is that, unlike accounting, being a PXpert is not as cut-and-dry.
Upside
It can be staffed with people at 0.9PX FTE rather than by people who are balancing PX needs with their other job descriptions. They have the freedom to define patient experience as they see fit within the needs of their organization. Within the organization, they can represent the voice of the patient without having to filter this through some internal audience or only within a specific subset of work.
Downside
Since they have more freedom to prioritize their work, they need to have as much skill at organization as they do at training PX. There are few people who come to PX as a jack of all trades. In fact, most that I have met are very talented at the soft-side of PX. They can empathize and use that empathy to create great training and excellent take-aways. These are the folks that I absolutely want to assist with patient-facing communications.
Less common are those comfortable with the data itself. Some audiences (doctors) want a harder analytical approach that some PXperts don’t have. These PXperts may be great at pulling reports and talking about the trends in the data, but don’t have the skills to squeeze more information out of the data by asking good research questions.
While most are great at problem-solving when it comes to PX initiatives, most are also not good at problem-solving when it comes to data architecture. It is not uncommon for a system to add or subtract doctors or clinics or change department IDs or CPT codes without notice. Then, six months later, when a clinic manager calls and wants to know why Dr X is not receiving surveys, PXperts aren’t comfortable performing data audits or problem-solving why things stopped working.
To be clear, these can all be problems when they are housed in other departments. When they are housed in other departments, though, there are built-in resources and clear networks to help with the work. When they are on their own island, though, they need that firm anchor to the system, so any conflicts can be mediated by leaders up the chain. Having them out on an island and not having an org-chart that is structured like other departments that tethers them clearly to the system will compound these challenges. Without clear leadership and a place at the senior leaders’ table, their function will not feel integrated into the overall vision for the organization. Instead, they will feel bolted-on and as such they may not get the oxygen they need to survive. Ironically, when senior leaders challenge their productivity and blame staffing or leadership, they will fail to realize that the real failure is in the organization’s ability to integrate the department into the whole.
So, every option certainly has its benefits as well as its costs. In the third part of this essay, I will explore what I think is the best model, second best model and third best model. Let it never be said that I only talk about problems and not solutions.
1Scheduling comes immediately to mind, since the scheduler must balance the patient on the phone wanting an appointment with the various rules associated with each individual provider or clinic about how they want scheduling performed for them. But at least scheduling has clear metrics, like call abandonment rate and call length, to measure performance.
2Though, I would say, much less than some think. Over a few decades, I have done thousands of presentations in front of tens-of-thousands of clinical staff. I have had active participation, thoughtful conversations and a lot of post-presentation work-group activities with both nurses and doctors to improve care. I have had plenty of nurses take me to their units to talk directly with staff; I have had countless doctors give up down-time so they could talk to me about strategies to improve perceptions. In all that time, I had one doctor walk out of a presentation once he learned that I was not a doctor. It is always the quality of the message and the treatment of the audience that is more important than the credentials of the speaker. Much more about my approach to presentations some other time.
PX Matters with Joseph Snipp 
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