Change is hard and it takes time. It takes focus, especially when this change doesn’t happen overnight or does not precipitate the desired outcome immediately. Anyone who has battled their weight knows that the excess pounds did not get added in one day and they won’t disappear in one day. Losing weight takes commitment and tenacity. Not for a day or a week, but for months. And, if you want to keep the weight off, it takes a lifetime change in your attitude towards exercise and diet. It would be unreasonable, even silly, to think that, in deciding to lose weight, the weight-loss would meet you half-way and happen just because you declared it as an objective. That it would happen quickly and without effort and be lasting. Why, then, do so many think that PX scores will go up simply because someone decided that they should go up? Why do so many think that the hardest part of changing PX scores is the decision to change and not, say, the hard work that goes into that change?
When stated like this, most people acknowledge that the change needed is more complicated than sending out a memo that says, “Everyone, be nicer. Thank you.” But this intellectual understanding still does not prevent the knee-jerk response to the lack of immediate results of demanding to change to a new process or program. This is partly because we have not done a very good job of educating them on why the kind of change we are imparting requires time to take effect. Here are four things to consider when communicating to leadership about the journey to improve the patient experience.
Tough Talk About Timelines
A point I have made before (and will certainly make again) is that senior leadership often does not understand that change in patient experience does not happen the same way that it does in other departments. Like Quality, change in Service does not happen simply by fiat. Goals, approaches, visions can be set by leadership and cascaded down. Even specific actions can be mandated. But, since the demand made by one voice must be carried out by a thousand hands, the request is the beginning of the change cycle, not the end. Decreeing that AIDET will be used is like decreeing that the Hester Davis Scale for fall risk assessment will be used. Until it is trained, validated, operationalized and consistent compliance has been established with all shifts on all days with all staff, the actual demand means nothing.
I remember talking with a CEO at a hospital who was frustrated that the PX scores had not improved as much as he had hoped over the first couple of months. When I reviewed the improvement plan that we established, his response was “Yes, but we did that last month!” His implication was that we needed to do something new, since that work was already done. I asked him to explain what “already done” meant and why he thought that plan would be fully trained, validated and be at 90% compliance in just a month. In the conversation, he realized that this plan was a bit more complicated than “Be nicer to patients” and while a lot of the work might seem intuitive, it was not engrained in staff behavior. Most staff were reasonably nice, but they were not delivering key words at key times, or narrating care consistently. Often, even if they were, they were not necessarily using words, tone or body language that made this information digestible by patients. So while the work had begun, it was not yet DONE.
So, it takes time to declare a plan implemented. Then it takes time for data to be collected with enough volume to make any declarative statement about the work’s impact on patients’ perceptions. Depending on the data submission schedule you have with your vendor and the turn-around time for surveying and the number of surveys you can reasonably expect in any given day/week/month, it may take a month or two to even have enough data to make a good evaluation of progress. This is especially true, if you have multiple touch-points in the data. The inability for a large unit (that has not been able to fully implement the plan) to move their scores may disguise the fact that a couple of smaller units has been able to move their scores up. Once you start breaking the data out by various key demographics, you may need additional time to see success.1
Further, people’s perceptions are not math equations. There is the belief among many that moving people up the satisfaction scale is a question of volume or frequency. So, one person being nice will move a patient’s score from a 0 to a 1. Ten people being nice, will move that up to 7. So, if we can get twenty people to be nice, that should get us a 9. While consistency is a key determinant in how people judge an experience, we simply do not think in this head-counting way. It is more accurate to think about perceptions as reaching a tipping point. Having a few people do the right process is not enough. We need to get to the point where most people are doing the right thing. We need to move from where one nurse’s grace is noticeable in a world of chaos, to a place where one nurse’s rudeness is noticeable in a world of grace.
This all takes time. Leaders need to understand that this is not like flipping a light switch on. It is like training an army. Of cats. With attitude. And other things to worry about on a day-to-day basis. Who don’t often trust that those leaders have the patients’ best interests at heart. This doesn’t mean FOREVER is the appropriate timeline. It only means that the needs of change management should be factored into any expected improvement. It also means that a lack of improvement in the data doesn’t mean that people are not trying, but only that we have not reached a critical mass of people trying.
Pick the Right Actions
While everyone follows the PX scores to track improvement (or lack thereof), picking processes and building action plans should be based upon what is the right thing to do and not what will move the scores. This may seem obvious, but it is not. I have had the same conversation with countless leaders in hospitals across the country. Invariably the suggestion they provide is “We should ask them, ‘if you cannot give me a 10, tell me, so I can address it.’” This seems like the right strategy because you are targeting the thing you care about, but it misses the point, won’t succeed, and actually will have the potential to make things worse.
It misses the point and won’t work for a host of reasons.
- That is not how people think. People do not start with a perfect score for a service and then deduct points every time you don’t deliver. So, you cannot reclaim those points by trying to do extra credit. People generally start with an average score and then add or deduct based upon elements they define as important.
- You will chase your tail addressing various random requests that won’t move the scores up and won’t improve the environment for the next patient.
- You will expend far more energy with this patient-specific model than on broad plans that will address 80% of all patient needs.
- You paint yourself in a corner when they ask for something you cannot deliver. Beyond “don’t bill me” or “give me morphine,” there are plenty of requests that you cannot provide them. Even a request of “move me to a better room” may not be doable, if even a “better room” exists.
Most importantly, it implies that you don’t care about them; you only care about getting good scores. Patients know that you have a hospital-full of people to take care of, but they don’t want to be reminded of the fact that they don’t really matter at all. By asking that question, you turn the whole process into some transaction, where I give you what you want and you give me a 10. This ceases to be about the patient at all. They are just a means to an end. When I mention this, the response is often, “Well, that is not what I meant!” but when pushed, they must admit that this approach does not send the right message to the patients.
But that is not even the bad part. By playing this game of “what’s it gonna take to get you to give me a 10 today?” you devalue the actual work of getting a 10. This isn’t about creating action plans to build a better experience. This is lobbying, perhaps pleading, for the end product without doing anything to earn it. If you think your frontline doesn’t trust you now, do you think that this ploy will actually make them think you care MORE about the patients? At best, they will think all this PX stuff is crap that doesn’t make the patient or the staff any happier. At worst, they will think that they can continue to do whatever it is that they do and their manager will follow behind, beg for forgiveness and a 10, and sweep up whatever mess they left behind.
Obviously, service plans should result in higher scores, but those higher scores should be based upon improving the environment for patients, so they want to give you higher scores. I am reminded of the movie Groundhog Day. Bill Murray’s character thinks that he can manipulate Andie MacDowell’s character into sleeping with him by learning, through trial-and-error, how to get what he wants. But it doesn’t work. Instead, he learns that by being a better person, he can create an environment where he can be loved by her. This is PX. You cannot trick someone into giving you what you want. You succeed only by being a better version of yourself and the goal you seek will manifest from that.
Differentiating Between a Learning Curve and a Plateau
It takes time to build the critical mass to really move the numbers. But there is also a ceiling for any action. A PX leader needs to be able to determine if there is still room for growth in an action plan, or if the data has topped-out and further growth will need further improvements in the action plan.
Shifting too early can lead all initiatives to feel like “flavor of the month” which means less emotional (and literal) commitment to the work at hand. Being too slow to tweak or add to an initiative can lead to backsliding and loss of focus among staff. Everyone wants to move an action plan from “the new thing” to “second nature,” but they fail to realize that without additional work or attention, that action plan becomes “old news” and is divorced from its core purpose and becomes “going through the motions.”
Further, no behavior has unlimited benefits. Put simply, one mint on the pillow is nice, but 700 mints on the pillow feels almost passive-aggressive. In health care and its siloed universe, this means that you can labor hard with the nurses, getting them the training and support to execute on every possible strategy. And your scores will go up. But at some point, there is a ceiling, and unless you get the doctors to play along, you are going to plateau below your desired goal.
One Target At a Time
This brings us to the final important point. Successful action plans will not divide attention by having seventeen new tasks to learn. They will focus on one new behavior until that behavior is hard-coded in the DNA. This is much easier said than done, because the fire for change burns very hot and some expect a new thing every week or month to push the data upwards. It is important to remember, though, that change in this dimension must be balanced against the competing messages staff are getting from Finance, Quality, etc. Service may “only” be asking for one new behavior modification, but it is not the only thing staff is being asked to do.
But this does not mean that PX must chase targets one at a time. We may ask the nursing staff to do ONE THING. We may ask the doctors to do ONE THING. Lab? Food service? ONE THING. All our audiences are only asked to do ONE THING. But the PX team? They are overseeing these various audiences with their one thing, so they have several things to manage. They have their own bandwidth issues and also need to prioritize work, but they are training and supporting not doing, so it is expected that they can manage multiple workstreams at the same time.
It can be frustrating when leaders do not give people the space to improve and have, at times, unreasonably aggressive timelines. The challenge for PX, then, is that we must at the same time, convince staff that the requested change is straightforward and easy to integrate while we convince leadership that change is hard and requires time.
1This is why I will always say that you cannot use data to be your first line of evaluation of a strategy’s success. You need to develop more immediate feedback (like direct observation or patient-rounding) to get information on your approach’s ability to connect.
PX Matters with Joseph Snipp 
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