In the first two essays, I explored why systems put PX in a variety of different places and discussed the values and concerns associated with storing it in these different places. Since I am one that doesn’t like to give problems without providing some solutions, or at point to the direction of a solution, I will take this essay to explore what I think are the gold, silver and bronze solutions to the PX org-chart Super-G Downhill Slalom. The key to these solutions is to make sure that once one has established where PX is housed, one also makes sure that the right pieces are in place as well. To that end, I will also discuss the perhaps less-obvious secret to success for PX in that environment.
Gold Metal—Stand Alone
My best-case vision is that PX should be treated as a distinct department that flows up to senior leadership. This is probably not a surprise to those who followed my previous essays, but this isn’t just a place where I am channeling my inner goth-kid “The world just doesn’t understand me and why can’t everyone just leave me alone?” vibe. I do think that PX is sufficiently different and sufficiently important to require a defter hand.
Sometimes the efficiency of the org-chart prevents the efficiency of doing work. You reach across the silos to ask for help and the other person says, “I don’t work for you.” Now regardless of their reason,1 you now must climb the organization level by level until you find their boss or their boss’s boss or their boss’s boss’s boss who will approve of and cascade down your request. Now you just hope that the crux of the request isn’t lost in this game of corporate telephone. Creating PX’s own space in the org-chart won’t prevent this,2 but when PX is housed under some other department, it creates two additional obstacles to this work.
- First, it adds another layer of leadership in the game of telephone to reach the right level where the cross-conversation can take place.
- Second, no requests come in a vacuum. All corporate requests require political capital as well as any other resource allocation. For example, if PX were housed under Clinical Care, a request to require formal training for a new PX initiative for the clinical staff will have to be balanced against requests for additional agency nurse staffing, and nurse union contract negotiations, and the CNO may decide that they don’t want to use any goodwill with the frontline nursing staff or senior leader team to mandate training.
Having its own pipeline to the senior level of leadership does not guarantee that any request will be granted, but it does mean that these requests will be put forward and lobbied for by someone who is also not trying to squeeze other things through. Especially when that senior leader sees PX as less important than, say, nursing staffing and satisfaction. So, it is not about PX getting everything it wants, so much as it is giving PX access to a more level playing field.
This leads to the other importance to having a clean line on the org-chart. PX needs to have an independent voice. This gives PX the opportunity to work with other departments as an equal, if not in size or importance, but in terms of hierarchy. It also gives PX an opportunity to call out gaps, missed opportunities, or downright errors. Can they really speak truth to power, if they are beholding to the powers that need to hear that truth?
I remember having an argument with a CNO, where we had this vicious logic circle going—the CNO did not want to tax her staff with new PX stuff, but also did not want to say that Clinical Care didn’t care about PX.3 If I were someone who had to answer to this CNO every day and was concerned about how my demeanor would impact all sorts of issues, from vision to staffing to budgeting, I might have been far more circumspect with them. As it was, I still lost the argument but forced a conversation about priorities without having to worry about being marginalized in any other conversations.
The secret sauce for success
The biggest threat to this model is that PX often will feel bolted-on and not integral to the operation of the system. This is especially true, if this was not the historic approach to PX within the organization. To that end, the only way that this can work is if an organization has mature leadership. No one complains that Finance is just ‘bolted-on’ and not integral to the mission of a hospital. Why? Because their value is fundamental to the language senior leaders use. Conversations about operational efficiencies and bending the cost-curve are baked into the senior leadership vision and planning. Leadership isn’t just focused on finances. They are envisioning ways to address looming problems, be that concerns over reimbursement schedules or the coming doctor and nursing shortages. They are focused on competition from traditional sources as well as up-start, nonstandard competitors who only want to peel off small lucrative pieces of healthcare delivery.
But all of this is just table-stakes. A truly mature organization understands that the patient experience needs to be baked into the work and not just a glaze on top of a finished product. In order for PX to work as its own element in the org-chart on equal structural footing to everything else, it needs a senior leadership team that treats it fairly to the other areas.4 If an organization’s senior leadership are not sufficiently mature to manage PX during the constant drumbeat of other issues, having it as a stand-alone department will lead to perdition.
Silver Medal—Marketing/Communication
If an organization is not ready for that level of leader maturity, then PX needs to be housed in some other department. As discussed in the last essay, all these areas have their pluses and minuses. The one, though, that seems to have the best opportunity for success in my opinion, is marketing. If you knew me and my history, you would know that I take no joy in giving Marketing the Silver Medal here. Some of my concerns were logged in my previous essay, but to be truthful, part of my reticence here is with so many marketing people I have worked with in the past. They too often seem to think that healthcare marketing is the same as any other form of marketing and aren’t sufficiently versed in the peculiarities of healthcare’s reputation in the marketplace.
In this situation, though, their unapologetic focus on connecting to the consumer is their best alignment with patient experience. I often say that the biggest obstacle for PX folks in healthcare is that they must spend the first fifteen minutes in any conversation justifying that patient experience is important. Housed here, they don’t have to explain themselves, since they are surrounded by people who already understand the value of building connections with people. Further, they understand the importance of measurement. They are familiar with how social science data collection models work to harvest top-of-mind recall or word-of-mouth loyalty. Plus, a lot of what they work on would benefit greatly from a patient’s perspective. I remember working with Marketing on a way to more efficiently and quickly on-board new patients to a health system. They completely understood, for example, that this process needed to focus on the patients’ convenience and not simply on a provider’s patient panel requirements.
The secret sauce for success
Marketing’s biggest blind spots are clinical experience and the real-world demands of the patient population. Having clinical experience there can be helpful, but the real value for PX in this environment is to have a clinical social worker (CSW) in their mix. These folks have experience working with clinical staff especially in the post-discharge universe. So they can often pitch training on the clinical side with an appreciation of the relationship between nurses and patients.
They also have the knowledge base of what the other challenges patients have in navigating healthcare. There is a reason why so much of the Social Determinants of Health work has CSW fingerprints all over it. They understand the issues of transportation, access to fresh fruits and vegetables, and the consistent access to medications that many hospital patients have. They can be, then, the voice of the patients, when it comes to everything from signage to new construction to the tone of letters threatening to fire patients for chronic no-shows to clinic appointments. They also are a good bridge between marketing and one of marketing’s organizational step-sisters: the hospital foundation.
Bronze Medal—Quality
In many ways, Quality is a good fit. They understand the clinical life without living the clinical life. They are deeply connected to metrics and measures, so while there is a learning curve to the social science world of measurement, they at least are well-suited to make that climb. They understand that things can go sideways and are well-versed at doing root-cause analyses to determine why things failed. This means that they are a talented and close-at-hand resource to assist with complaints and grievances. They are also very comfortable leading initiatives to change behaviors as well as creating in-the-moment measures to validate that work. They can reinforce hand hygiene or fall protocols and can also create measures to validate compliance with that work.
Frankly, in most ways and in day-to-day operations, they are better than the Silver Medel winner, Marketing. The only reason why I don’t put them higher on the list though is because I cannot think of an institution where they have a direct line to the senior leaders. In every place I can think of, they still route up the org-chart through Clinical Care. So, in terms of climbing the organizational ladder to get attention, PX would have to compete with other things in Quality for attention before they could compete with other things in Clinical Care for attention before they could compete with other things system-wide for attention. If an organization gives Quality/Risk more prominence in their org-chart though, it would definitely be my preferred resting place.
The Secret Sauce to Success
If housed in Quality, the most valuable person to have in PX would be a data savant. Since, as mentioned before, there is no more metric-centric5 department than Quality. So having a PX person who could design and implement measurement strategies for PX initiatives would be able to communicate most effectively with Quality. Since they put a high premium on performance, being able to point to compliance and even be able to show how improved compliance on the PX initiative correlated to PX scores, would allow PX to successfully fight for oxygen in the Quality realm. This does not mean that they must be statistical geniuses, only that they can translate broad behaviors into concrete measures that are easily and accurately collectable.
Regardless of any model, though there is one thing that PX must have. They need a confident leader who can be a voice for PX in the maelstrom of competing demands and issues. It is not that PX shouldn’t have to compete with other important areas, but PX needs a leader who is not afraid to, when necessary, raise their hand and be heard. This requires a leader who is comfortable in this position and won’t be cowed by other leaders who have (perceived) more important portfolios. This doesn’t mean they must be strident, necessarily, but they must be someone who can put PX first in their list of priorities and know that it is worthy of attention and the big-boy table. With that, PX can succeed in any situation (considering the potential pitfalls outlined) and without that, PX is likely to flounder in any of those situations.
1I don’t mean to minimize or trivialize this obstreperousness. Sometimes this hesitancy is important and real. For example, many organizations have various ticketing systems, where, to get something out of another department, you must submit a ticket and it needs to be reviewed, approved and slotted in the workflow to prioritize the request. That other person may have their job performance based upon ticket closures, so asking for something on the side may decrease their official productivity numbers.
2I am not sure if there is a more amusing corporate contradiction than the clarion call of Tear Down the Silos, even as a thousand things are erected to maintain the silos. If you say, “But, Joe, I work in a matrixed organization so we are different,” I will have to set down my coffee to wipe the tears of laughter from my eyes. Please, anyone who works in a so-called matrixed organization and feels like it is less siloed than any other place, please leave a comment below. I am sure your organization would also like you to leave a review on GlassDoor as well.
3Memory serves that somewhere in the 70-80,000 words I have posted here that I told this story before. If so, well, I am sorry, but since most of my stories have multiple uses, it is not likely to be the first time nor the last time that I will repeat myself. If I contradict myself, well, I encourage you to call me out on that.
4Notice that I say ‘fairly’ and not ‘equally.’ My point is not that PX is equal to all other elements. There are days when a budget shortfall or contract negotiations will take up all the oxygen. So, it is not about PX always being first, so much as PX not always being last.
5I think a prog-rock band or math-rock band or free-form jazz collective could do worse for a band name than Metric-Centric, so if you are in one, feel free to use it. I just ask that you send me your first album.
PX Matters with Joseph Snipp 
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