I know that I owe you the second essay on being nice. In my defense, in the construction of that essay, I realized that there is a topic that needed to be addressed to understand why hospitals struggle with the structure of patient experience. It started as a paragraph, then two, as I started a third paragraph on the topic, I realized it needed more breathing room. Since it is important to discuss before we can talk about the ways to build organizational structure behind PX initiatives, here I am. I briefly considered calling it Being Nice Version 1.2, but then I thought that was way too coy.
Healthcare suffers from low self-esteem. I know this statement will make some roll their eyes so hard, it will knock them out of their chair but bear with me. I know healthcare feels like an ivory tower, filled with people who are smarter than you, know that they are smarter than you, and continually remind you that they are smarter than you. The world of recovery, though, has a phrase for that. Healthcare is like an egomaniac with an inferiority complex. Or, perhaps, more accurately, healthcare is a complex organism, filled with a lot of people. Some are egomaniacs and some have an inferiority complex. In combination, you sometimes get borderline codependent behavior.
Healthcare requires a lot of skilled individuals. On the clinical side, just about everyone needs to be well-trained and licensed. This means that there is a premium for well-trained staff with current licenses. Hospitals in rural areas need to beg and plead for qualified staff to come to them. Hospitals in urban areas are panicked that their staff will leave them at any minute for the hospital across town. They all give off a very needy vibe.
On the non-clinical side, hospitals often pay less than other industries. One of the biggest surprises for most people is that hospitals operate on razor-thin margins. The average hospital is lucky if it is operating at a 3% to 4% margin and many are lucky to maintain a 1% to 2% margin.1 Overlaying this with the fact that hospitals often have higher standards than other industries, this means that they pay their housekeeping staff less than a hotel might, but must hold them to a much higher standard of cleanliness.
This has meant that they often let staff, or at least SOME staff, walk all over them. They are so concerned with high levels of turnover that hospitals try to reduce any corollary expectations placed on the staff. This is why clinicians can get away with saying things like, “I am here to save your ass, not kiss your ass.” What if we push back at that seriously crabby emergency department doctor and they just quit?!? What would we do then?
And some clinicians lean into this. There is a reason why the stereotype of the self-important doctor exists. I remember talking to a cardiothoracic surgeon in Chicago once who literally told me, “With all the money I bring to this hospital, I don’t have to be nice.” As you can imagine that conversation on the patient experience did not go anywhere productive.
Hospitals tolerate this behavior because certain staff members are critical for hospital operations. Another thing that the public may not be aware of is that hospitals need certain types of staff to offer some services. Rural hospitals are ending their birthing programs, not because there are no patients, but because they cannot keep an obstetrician on staff, or OB-trained nurses. Confronted with losing service lines, hospitals will do what they can to keep staff.
As you know, I often paint with a broad brush. Not every hospital bends over backwards to keep clinical staff and certainly not all clinical staff are jerks. But in an industry that understands the critical importance of collaborative teamwork and tearing down silos, hospitals often seem to undervalue team chemistry.
One of the enduring gifts I received from my brief exposure to economics at Creighton University was learning about Gresham’s Law. Gresham’s Law states that bad money forces out good money. So, for example, in 1970, when silver was removed from all circulating American coins, all coins minted before 1965 became more valuable because of their silver content. As a result, people would keep the older coins and use the new coins because the older coins had more intrinsic value. In this situation, it didn’t take long for all the silver coins to disappear from circulation because they were all put in a coin jar in someone’s attic.
It is not hard, though, to see this effect in other spaces as well. As a social scientist, I see this in so many different social interactions, where bad people drive out good people. If you don’t know what I mean, check what social media has become and get back to me. In any employment situation, adding a toxic personality can destroy the culture or chemistry of a workplace and the talented employees with options leave for greener pastures. What is left? People who have no options, either because they are less attractive to other employers or because of personal reasons that lock them into their current job.
This is the thing that healthcare doesn’t understand. Keeping toxic people around drives good employees away. People know that mistakes are made in hiring. That great candidate on paper doesn’t always work out in real life. 2 Staff know that not all hires will be home runs. But staff also pay attention to how those employees are treated by leadership. If their bad behavior or poor performance are tolerated and the employee is not coached-up or moved-out, the staff ask an obvious and reasonable question. Do you not KNOW that this person is a problem, or do you not CARE that this person is a problem? Of course, this is a trick question, because either way, the remaining staff start looking for the exit. Why should they work for a company that doesn’t value quality team members or, worse, doesn’t recognize was a quality team member looks like?
What is worse is that this poor performer starts sucking the efficiency out of the remaining team. I remember working on a root cause analysis about an error in a hospital emergency department, where the wrong patient was given medicine. It didn’t harm the patient who got the medicine, but it did delay the treatment of the patient who needed the medicine. In talking to the nurse who dispensed the medicine, he said, “I didn’t think that it was right, but I didn’t verify with the doctor.” When asked why he didn’t, it came out that the doctor had a reputation for yelling at nurses who asked validating or clarifying questions. She tolerated only one question, “How high?” when she demanded that they jump. So here was evidence that not this talented doctor with a horrid disposition actually made the staff worse. Had the nurse felt comfortable asking a question, a problem would have been averted.
Sadly, we see this all around us. I imagine many readers can think of people they have worked with whose demeanor and ability made those around them less productive, either because they were spending time fixing that person’s mistakes, or because they were spending time protecting their own hindquarters against their wrath or incompetence. OR, if we are going to be honest, NOT fixing their mistakes in an effort to expose their incompetence or negative attitude. It is one thing, if I stop fixing a coworker’s constant errors with its/it’s or there/their/they’re because they are a pompous self-important jerk. No one has died for the lack of a stylebook. It is another thing to let a patient get the wrong medicine because they want to expose a physician’s incompetence. To be clear, I don’t think the nurse in my story was doing that, but I do think that not addressing these employees can lead to damaging outcomes due to frustration or petulance.
The greatest heartbreak is that in tolerating this behavior, employers are missing out on an easy way to gain respect from their team. No one hates the bad more than the good. No one hates bad cops more than good cops. No one hates bad teachers more than good teachers. No one hates bad doctors more than good doctors. Why? Because they ruin it for the rest of us. I prided myself on my teaching ability and resented the stereotype of college professors being puffed-up self-important blowhards. The easiest way to score points with your team is to face bad workers head-on. The secret is that in the short- and mid-term, staff members would rather work short-staffed than have to walk on eggshells around that one employee. In the long-run you gotta replace them, but you were going to do that anyway. But you also bought yourself a bit of time, because you can tell your team that we need to hire for fit and not make the same mistakes over again.
Instead, employers will downplay that employee’s flaws as less important than what they bring to the table. Sure, that professor stinks at teaching, but they are a grant-money-magnet. Sure, that doctor is a jerk, but who else will practice in this one-horse-town? Yeah, that surgeon is rude, but what if he takes his services to General Hospital across town?
The reality is that, given the stress of staffing, the meager profit margins, and the uncompetitive pay, hospitals will tolerate the disrespect they get from staff that are “just not that into you.” If they must sacrifice the patient experience, well, at least that staff help us can keep the doors open.3 Once, in arguing in favor of soft-pedaling a PX initiative, someone said, “but you don’t know what our doctors go through.” To which, I responded, “but do you know what our patients go through?”
Some hospitals are learning, though, that the world does not end, if you establish boundaries. I remember working with a hospital in a small two-hospital town. They had a cardiologist who would threaten to jump to the other hospital every time something changed. Any time they tried to standardize the medical equipment4 or tried to move his parking space, he would say he would leave. They finally said, “Fine, then leave.” And he did. Eighteen months later, he was back, having worn out his welcome across the street. Now did he learn his lesson? I am not sure.5 But, the hospital learned that they could set clear boundaries for behavior and the world did not end.
Now this is not to say that hospitals should let the pendulum swing too far the other way. Hubris is not a better place to function. This is to say, though, that this low self-esteem has costs. Some are literal costs and some are hidden costs. Some burden other people more than you, but everyone suffers. I simply ask that you look in the mirror and ask what your low self-esteem and inability to set boundaries is costing you and the ones around you.
1There was massive press when Walmart and Amazon announced that they would enter the healthcare market. Much less was made when they left (or significantly curtailed their presence) in the healthcare market. They discovered that the profit margin on bathrobes and game consoles was significantly higher than on primary care visits and cholesterol medications.
2Whenever I use this analogy, I think of the old line, “That hockey team looks great on paper. Too bad they have to play on ice.”
3I know that this seems broad and whiney. Please accept my apologies. But then, look at the time, resources, staffing and attention that a hospital gives to patient experience relative to every other dimension and tell me if I am wrong.
4Another secret that people don’t know is that, in an effort to cater to the doctors, hospitals will keep a variety of different kinds of medical equipment on-hand for their individual preferences, which marginally increases the costs because they cannot streamline purchasing. Since this is the third secret in one essay, I will have to write an essay about all the dirty little secrets in healthcare.
5There is another phrase in recovery, though, that says, “no matter where you go, there you are.” If you change your situation, but not yourself, your situation won’t stay changed. So, switch hospitals if you want, but you are still an asshole.
PX Matters with Joseph Snipp 
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