Why PX Efforts Fail: Lack of Integration

A theme from a lot of my essays is that patient experience is not always fully integrated with hospital and clinical operations.  It often feels overlayed or tacked-on to other work and not treated as an end in itself.  It is often treated as a shiny coat of paint or optional equipment rather than something that will improve the efficient performance of a new car.  I once worked with a health system that was breaking ground on a new hospital.  The entrance seemed confusing, as the blueprint indicated that the front desk was twenty or thirty yards from the main entrance and obscured by a wall.  When I observed that this didn’t feel patient-facing (either figuratively or literally), I was given a dozen reasons why this design was chosen.  I was assured that there would be helpful signage.  I mentioned that, with all the unexpected elements dealing with patient flow and a welcoming first impression, it seemed odd that you would start with a problem that has to be fixed.  But I wasn’t actually part of the design team, and my comments did not feel welcome, so I nodded and sat quietly.  I should someday go to that hospital and see what signage they have installed. 

I don’t mean to sound petulant about the lack of concern over how patients would navigate the space.  I was not angry at being discounted.  It was simply one of a number of examples where a thoughtful conversation about the patient and family experience is deemed less important than other concerns.  I am sure that the finance folks deemed that additional signage was less expensive than redesigning the footprint of the hospital.  It wasn’t the only issue,¹ so I should make a point to visit that new hospital someday. 

The point of that story is that if you don’t take the time to integrate your patient experience work into your broader system plan, it can feel clumsy or bolted-on rather than integral and seamless.  One of the reasons why PX efforts fail is that they are not integrated to the larger work plan.

Not Connected to Purpose

You may have noticed that I often say that initiatives always fail.  The reason I say this is because they are created to spark change and too often this need for change is their only explanation or justification.  Yesterday we weren’t doing AIDET² and today we are.  Yesterday we weren’t doing rounding in the emergency department and today we are.  No effort is made to build understanding or appreciation for the work.  It is assigned.  Staff’s response is often the same response the average 14-year-old has when confronted with algebra.  When am I ever going to use this?  Why is it important?  Assigning this work without doing the effort to connect it back to its value to the patient and the staff, you have simply given staff another task that they will call “busywork” and likely ignore when patient acuity or census grows. 

Further, the word “initiative” assumes an end-date.  If it didn’t have an end-date, it would just be sold as the new standard operating process.  Since it is not communicated as a new standard, but simply a new thing we have to do, the implication is that this, too, will go the way of the dodo bird and the traveling call³ in professional basketball.  Consider how many times you have sat through some new training only to have its lessons completely disappear from all usage and language in three months. 

If a process is not connected to purpose, it will be abandoned.  It is not sufficient to say that its value is obvious or foundational.  Exercise and proper diet are also obvious and foundational to healthy living.  And yet, we all are guilty of wolfing down fast food while we work sedentary jobs.  We will even say things like “I shouldn’t be eating this” as we eat it or “I should be taking the stairs” as we wait for the elevator.  Even if we identify a behavior as part of the overall mission of the work, it will fail.  Calling out abstract concepts like “Putting the CARE into healthcare” won’t work.  It will likely engender more eye-rolls than compliance.  I will take the time to discuss how to build compliance another time.  For the moment, trust your eyes.  When you assign tasks without context they aren’t done with the requisite enthusiasm or they are not done at all.

Not Culturally Congruent

Many forests have been clearcut, generating the paper to publish books on the importance of corporate culture.  Often, though, these books focus on one sort of culture, and it is not the most important sort of culture.  Most people talking about culture are talking about staff behavior.  We cannot create broad behavior changes in staff if we tolerate shitty employees behaving in shitty ways.  This definition of culture focuses on holding people accountable.  I will certainly not argue against that.  If you let some people get away with not honoring appropriate behavior because of their title or RVUs⁴ then no one will take the work seriously.  Clearly, if you have different rules for different folks, you need to address that, but that is a separate matter.

But just as important, if less obvious, is the culture of how an organization functions.  All organizations have different expectations.  Some follow a rigid hierarchy, where all important decisions are made at the top and cascade by a clear communication structure.  Other places have a more matrixed organizational structure, where people can have sold-line and dotted-line relationships with multiple leaders and have to prioritize the messages they get from them.  Some place great emphasis on the chain-of-command and others stress a more amoeba-like collaborative model.  If one does not acknowledge how work is prioritized and distributed in an organization, one can stumble before even beginning.  A classic example of this is when a new process is decreed and trained in a massive auditorium, but when a floor nurse asks their unit manager a question about it a week later, the manager says, “I don’t know, call someone else.”  By not bringing in those managers to advocate and educate in the moment, one has failed to use the corporate culture to effectively execute change.  When approaching training, one needs to consider a few questions, including the following.

• How do front-line staff usually get instruction?  Do they get it from their leader, a peer who is a subject matter expert, from the clinical education department? 
• How is that training usually delivered and validated?  Is it with short training sessions done in the workspace, longer sessions in a meeting room, or asynchronously via videos?  Is it validated with check-lists, peer rounding, shadowing, or quizzes?
• How much bedside modification is allowed?  There are certain elements of healthcare that are non-negotiable.  Others, though, acknowledge that the emergency department, finance, food and nutrition services, ICU, and specialty clinic care spaces are different with different patients having different demands.  Effective training needs to differentiate between system-standard and departmental deviation.
• Who owns compliance?  Normally, managers are given the responsibility of assuring compliance with a process or procedure.  The person who is likely to receive the beating for failure takes the most attention for execution.⁵ 

Cult of Personality

It is important that all processes in any industry have a face.  Someone who stands behind a required activity to explain it and answer questions.  Most hospital clinicians know who the person or team in charge of infection prevention is.  They likely know who is in charge of reporting out the quality measures, like adverse drug events, surgical site infections, or hospital-acquired infections.  They also probably know the local PX person.  What can differ, though, is how that face aligns with the work.  There is a structure that undergirds the work.  If the Chief Financial Officer leaves, it is not likely that paychecks won’t go out, or that accounts receivable won’t send out invoices.  The process will not grind to a halt.  That is because there is a structure under the CFO that remains present, even if she/he leaves on vacation or for another job. 

What can change, though, are the things that were prioritized in that department.  An organization’s appetite for running short-term losses against a strategic vision or a demand for aggressive return on investment (ROI) calculations for material purchases tends to be driven by the person and their preference rather than the objective machinery that does the work.  All infection prevention professionals are concerned about hand hygiene, but the extent that it is prioritized in their work relative to other concerns is dependent upon the person. 

In patient experience, the structure is often less-defined than in other spaces.  This is more than simply having fewer staff members.  PX also tends to leave more elements up to the decision and discretion of the Vice President of PX or CXO.  Things like how training is done, what tools are used, and what data is used to measure success are often left to the leader’s decision-making preferences, even if they are then filtered through any committees for agreement or funding.

This means that what generally saves PX work in this environment is what can kill it.  Folks in patient experience leadership tend to be unafraid of the spotlight.  They likely do not have significant problems talking to the c-suite or to a room full of doctors.  Their passion for the work garners them attention and people often recognize them.  Some accept this attention begrudgingly and others are more comfortable with the attention.  Nancy Miller, who often reads these essays, might point out that I belong to a third category, those that actually bask in that attention.  She is perhaps not wrong, which is the closest I can come to saying that she is right.  I would defend myself by pointing out that since PX is more about the HOW than the WHAT, bringing energy, humor, and bombast to a presentation or meeting is what the subject actually needs.  If I need to have staff delivering memorable experiences, then I need to bring memorable experiences to that training.  If I need the CEO to support spending that may not have a direct ROI, I need to bring as much passion as I bring receipts.

The problem with this, though, is that when the CFO leaves, priorities may change, but the work goes on.  When the PX champion leaves, if the underlying structure has not been fully realized, the energy associated with PX also leaves.  I remember visiting a hospital in Washington state where the CEO was all-in on PX.  (I think I told the story about the standing ovation given to a receptionist.)  I went there and did some presentations and worked with their team on establishing some PX work.  At that time, he confided in me that he was soon to retire.  I wished him well.  When I returned a year later, he was gone and it was clear that PX work was foundering.  A year after that, I went to kick-off a renewed focus on PX under the new CEO, who did not attend any of my sessions.  I haven’t been back since and I just checked their publicly-reported scores.  They are performing over twenty percentage points under the national average and nineteen points under the state average.  Their scores for doctors and nurses are likewise well below any benchmark.  All of these scores are at least twenty-five points below what they were when I was last there.  To be clear, I am not saying I bring the thunder and the rain.  I am merely pointing out that the CEO who left was never able to build structure around his passion for PX.  So, it became a cult of personality and when the personality left, so did the focus. 

If a hospital does not do the leg-work to build out a corporate commitment and a program for patient experience and instead focuses on the sugar-high of a new initiative or charismatic leader or consultant, they won’t get any long-term benefits from anything targeting the patients’ needs that should live where the patients receive care.  If it isn’t integrated, it will be ignored and forgotten. 

¹For instance, the internal floorplan necessitated bulk food deliveries for the cafeteria travel through an inpatient unit.  As someone who spent a couple high school years carting foodstuff from a storeroom to a restaurant through public spaces at a mall, I know how customers can respond to that.

²AIDET, IHEART, RELATE and other acronyms are mnemonic devices designed to remind staff how to communicate with patients.  In my experience, they are often discussed and rarely used by staff.  If you are curious if they are being used by your staff, you can either ask them what the acronym stands for and watch them fumble, or you can just assume that they are not, unless you are provided with evidence that they are.

³For those who are not fans of professional basketball, it is against the rules to take a step without dribbling the ball.  To do so is called ‘traveling.’  If you watch a game, though, every move to the basket involves someone taking one if not two steps without dribbling the ball and it is never called. 

⁴Relative Value Units (RVUs) are a way of standardizing work in healthcare.  These can take many forms and calculations but essentially are designed to measure the relative value a doctor brings to a hospital or practice.  What is more valuable: a primary care doctor with a panel of one thousand patients, or a cardiac surgeon who performs a dozen surgeries?  I would say that this tends to focus on the bottom line and not the service to the community, but I have already been a bit pissy about the topic today and will forego this observation.

⁵For the record, I have RARELY seen direct managers given responsibility over compliance on PX matters.  This usually falls to someone in PX or considerably up the food-chain.  This gap between who manages this and who gets punished for noncompliance can lead to a differing level of attention it receives.