Why PX Efforts Fail: Lack of Focus

In any effort to change processes or behaviors there is both the desire to succeed and the possibility of failure.  While there are always immutable facts that make success difficult (and sometimes impossible), we too often define failure as simply a lack of desire to succeed.  In addition to the fact that this can be extremely judgmental¹ it is overly simplistic in discussing why something failed.   Not only is it reductive to blame desire over a thoughtful analysis of the failure, it all but guarantees that we are likely to repeat those mistakes instead of learning from them.  Initiatives in patient experience often put a significant burden on behavior modification over anything else, so they are especially susceptible to the explanation of failure as simply a lack of desire to improve.  Over a series of essays, I will explore what often causes PX work to fail, and *spoiler alert* it isn’t the lack of desire.  In this essay, I will discuss the most basic reason why this work is not successful.  It is because the PX work often does not have sufficient focus on the work and expectations.

Unfocused Goals

When starting a new project, the first questions one should ask are: 

• What does success look like? 
• What does failure look like?

Often the answers to these questions are assumed.  Duh, it is a success if the patient’s experience gets better.  This is simplistic and unhelpful.  What experience?  What does it mean to get better?  If this question gets patronizing and simplistic answers, the other one doesn’t get asked at all.  If pressed, some might say, well, it is a failure if the patient’s experience doesn’t get better. 

I dislike these answers not just because they are simplistic, but also because they are overly broad.  The first thing one should realize about success or failure is that this is not a coin-flip.  It is a spectrum.  If things get a little bit better, is that a success, or does it have to get a lot better?  What if it doesn’t get better, but it doesn’t get worse?  What if things get better in some units, but worse in other units?  What if by some measures things improve and by other measures things get worse?

If forced to answer this question, teams will create measures for success or failure and in patient experience, they will often point to survey results, declaring that it will be a success if the scores improve by a specific number.  This may help set a definition for success, but it may confuse what constitutes a failure.  We set our goal as an improvement by five percentage points, but we only improved by four percentage points.  Is that a failure?  What if declines but only within the margin of error?  Does that count or is that just random chance?  What if the score improves, but only within the margin of error?  Are we consistent or hypocritical?  I could chase this down a rabbit-hole, but the point of this discussion is not to say that all goals are illusions is that life is pointless.  My point is that if one does not dedicate some time to discussing what success (and by extension failure) looks like, you already are setting yourself up for failure.  Imagine the conversational car wreck when a unit manager who sees the scores go up by four points to the highest score in five years as a massive success meets with a senior leader who sees missing the target by one percentage point and calls the year a failure. 

Improper Goals

Pegging success or failure to survey results is not horrible, but it can be lazy.  Too often, the goal is set on some broad overall question like Overall Rating or Likelihood to Recommend (LTR) because that is on the system pillar, even as the actual initiative is focused only on some part of the patient’s experience.  For example, a good PX objective might be to hardwire² nurse hourly rounding and bedside shift reporting.  Often the plan is to stress these tools and then log onto the survey portal and hit ‘refresh’ to see if the LTR score went up.  Can I see a show of hands of who thinks this is an improper goal?  I could list a dozen reasons why, but they all revolve around the fact that LTR is based upon a myriad of things.  It certainly can include nursing performance, but it also includes physician performance, staff performance, convenience, past experiences, hospital reputation, just to name a few.  So, if you decree implementation of hourly rounding and the scores don’t go up, we are not sure why it didn’t work.

• It was decreed, but not implemented
• It was implemented unevenly or poorly
• LTR involves things that the initiative did not address

Picking a goal simply because it is on the pillar is lazy and does not create an environment where we can accurately identify success or failure.  Here, by focusing on the specific questions addressing nursing behavior—nurse explanations, nurse listening, nurse compassion—we have something that comes closer to a measurable ‘effect’ based upon the initiative’s ‘cause.’  If one is going to select a survey measure to determine success or failure of an initiative, it should be proximate to the behavior that the initiative is seeking to address.  More on that another time. 

No Clear Rules

I have written in the past how an initiative like “staff should always be nicer” is destined to fail.  All behaviors need a triggering event.  If that triggering event is the start of a staff member’s shift and remains active every moment until the staff member clocks out, then that initiative will fail.  They won’t work either because they are so basic as to be pointless or too broad as to be exhausting. 

• Yes, it is a good idea to “never punch patients in the face,” but this so basic and obvious as to already be in place and not likely to have a positive impact on patient perception.³
• Some might think that a plan that requires all staff to “always address negative comments” would be useful, but it will be ignored by staff.  Are you really expecting a staff member who overhears a family in the cafeteria say, “I am not happy with the care Steve is receiving” to hop up, insert themselves into the conversation, and address that?  If you DO expect that, well, I am sad to inform you that staff won’t ever do that.  If you DON’T expect that, then create rules that truly reflect what you expect staff to do.

By not having clear rules, you can often descend into definitional quicksand.  Sometimes it can seem like people are being purposefully dense or obstructive when they ask, “But what if someone wants me to punch them in the face?” or “OK, but can I slap them in the face or punch them in the arm?”  But often people are simply asking for clarity.  I worked with a hospital system and was asked how often they should review their data.  I said that it was reasonable to review the data weekly.  This was unchallenged until one of the critical access hospitals pointed out that they might only get two or three surveys every month, so this seemed like overkill.  They were not being difficult, and they were not being passive-aggressive about their lack of surveys.  They were honestly trying to balance the system expectation with their personal reality.  They wanted to avoid discussing the same two surveys every week but also wanted to avoid getting dinged by the system for not honoring what Snipp suggested.

Wrong Focus

Ideally, an action plan is based upon a review of past performance, looking at the data, comments, and/or feedback from focus groups or patient/family advisory councils.  In the real world, action plan targets are often addressing the questions with the lowest scores, or things that are unimportant but easy to fix, or the pet project of leadership.  Sometimes leadership wants to avoid stepping on a third-rail and getting shocked.

The lowest-scoring questions seem an obvious target, but it may not be the most important element in a hospital’s overall scores.  The most obvious example of this is food and nutritional services (FNS) scores.  Questions about hospital food are often the lowest in any battery of questions, but they are not the most important questions driving overall satisfaction.  Serving five-star cuisine on fine china by candlelight, with Michael Bublé singing in the corner will certainly improve FNS scores, but they are unlikely to improve Overall Quality, because that is not what patients are looking for in a hospital. 

Many organizations will focus on harvesting easy and quick wins, which is certainly a way to build confidence and interest in PX initiatives.  But if those easy wins have little impact on the overall patient experience, then you may win the battle, but lose the war as both staff and leadership will not see the work as making a difference.

Many will look to their leadership for guidance.  This can be helpful and valuable to keep leaders on-board with the work.  But leaders can have misconceptions about the patient experience, or concerns about some PX work.  I have seen senior leaders want to focus energy on work that is cosmetic at best.  I have also seen senior leaders express concern over creating action plans addressing clinician behavior for fear of making it difficult to recruit and retain physicians or straining relationships with nursing staff and their unions.  If senior leaders want to pursue or avoid certain bodies of work, that is their prerogative, but it is the PX leader’s responsibility to point out what impact those decisions will have on the ability to improve the overall experience. 

Too much too soon

Asking any staff, clinical or non-clinical, for too many behavior modifications at once won’t work.  I know that I have discussed this in the past, so I won’t belabor this, but asking staff to absorb ten new behaviors at once will work as well as adopting ten New Year’s resolutions at once.  If the PX champion and the senior leaders want to manage multiple plans, that is fine, so long as they are only asking the nurses, doctors, receptionists, housekeepers, and FNS staff to do ONE thing.

It is easy to accept that appropriate focus is key to success with PX work.  What is difficult is when you move past the superficial and dive into what makes this focus appropriate.  Too often the acceptance of generality papers over the disagreements and differences that often lead to failure.  I say that PX failure is not an absence of desire.  If fact, if there is no clear focus on an initiative it may be better if some people do nothing rather than having people are all rowing in different directions,

¹When you accuse an obese person or a smoker of having no will-power, you reduce the battle between addiction and incremental improvement with a dismissive wave of a hand, decreeing that the person just doesn’t want it hard enough. 

²I am not happy to use buzzwords like “initiative” and “hardwire,” but they are easily understood, even if they are problematic.  As with so many things, I will put a pin in them and discuss my dislike later.

³I will estimate that I have read over 100,000 patient comments in my life in PX.  I can say with great certainty that I have NEVER read a comment that said, “Wow, they didn’t punch me in the face, so 10 out of 10 points!”