Challenges with Building Compliance: Time

One of the pushbacks on patient experience initiatives is that they are divorced from clinical practice.  This is often captured in the dismissive phrase that patient experience is “mints on the pillow.”  When confronted with this statement, I will roll my eyes but then say that I WISH patient experience is that simple.  If that is all that PX is, I could buy a case of mints, hand them to the housekeeping staff, and then take a very long lunch.  The comment is meant to dismiss the work as silly, but its bigger sin is that it dismisses the work as easy and clear.  In reality, PX work is not about talismans or totems, it is about delivering key behaviors, consistently by all staff, with all patients, each and every day.  Putting a mint on the pillow takes less than a second and could be done by anyone.  It is also easily validated, since it would likewise take less than a second to look into a room and validate the mint’s presence. 

I have written in the past about how, in order for processes to be effective, they need to be rooted in clinical purpose.  For example, hourly rounding on patients or sitting down when talking to a patient/family are only executed and effective if the staff understand why this process is valuable.  Having said that, even if you have connected process to purpose, there are still reasons why these initiatives fail.  In a series of essays, I will explore why building compliance is challenging and what we can do to help overcome these challenges.  The first hurdle is that new processes take time to implement.

Cost of Time, Actual

We have all heard (and some of us may have said) the phrase, “It is easier for me to just do something than to teach someone else how to do it.”  I cannot think of a single time when this sentiment was NOT true.  So why bother training people ever?  Because speed in task-completion is not the only variable we are interested in managing.  Whether we are trying to consider a succession plan or creating a process that doesn’t have a single point of failure or pushing people to work at the top of their license or just imagining a universe where we could take a day off, training other people to do work is not about the next five minutes, but about the next five months or five years. 

In theory, the added PX work should be seamless.  In practice, it takes time to build a flow.  One thing that is incredibly helpful for patients is when staff narrate care.  This is when a staff member tells a patient what they are going to do and then they do it and then tell a patient what they just did and what the next steps are.  Ideally this can be done as the work itself is being done, but early on, it can seem difficult to do both at the same time.  If you have ever tried to explain what you are doing while you are doing it, you know that this is not the simplest thing to do.  At some point, either your words or your fingers will fumble or trip as you are trying to focus on two things at one time.¹ Building muscle memory by preparation and repetition is key. 

This fact leads to two mistakes leaders make in rolling out something like narration of care.  First, some leaders fail to account for the added time needed for a task.  All new tasks take time to internalize and take time to execute.  Even if this new time is considered akin to chewing gum and walking (that is, ideally something done while one is doing something else), it still takes time to fold that work into existing work.  This is especially problematic when, in day-to-day work, efficiency is primarily, if not exclusively, defined as time-management.  Even if overall hospital performance is measured in positive outcomes, this rarely makes its way down to the bedside.  So, actual length-of-stay as a ratio of expected length-of-stay, or sepsis mortality, or slips and falls, are all important measures.  But rarely have I seen these measures translated into bedside conversations.  Alarms, call lights, pagers, phone calls, and nurse-to-patient ratios are far more immediate than taking an extra couple of minutes to go over how important it is that a patient not try to get up from the bed without asking for help. 

The second mistake that some leaders make is that they minimize the time and its impact on broader performance.  I have mentioned this story before, but I remember talking with a lab director about his frustration that staff was not greeting patients, narrating care, covering the issues being tested for, labeling samples in the patient’s presence, and talking about how long before the results get posted while they drew blood.  He lamented that this only took a couple of minutes to do.  I pointed out that this might be true, since they did forty blood-draws a day, this work, by his own admission, added an hour and a half on to their day.² 

By both demanding a process change while dismissing its impact on efficiency combines to ignore the real-world challenges that staff faced.  This likely meant that this work was not being done consistently and was likely not resonating with patients.  Depending on that leader’s reputation, it might also mean that staff lied to that leader about their ability to execute on that vision. 

Cost of Time, Mental

As annoying as it is to discount the real cost in time that any new process incurs, this pales in comparison to the perceived cost of time in the minds of staff.  How much time someone THINKS something will take is far more powerful than the actual amount of time something will take.³

I want to learn how to draw.  Any artist will quickly point out that the best way to learn how to draw is to draw, just as any musician will say that the best way to learn how to write songs is to write songs.  But for me, the gap between where my skills exist and where I would like my skills to exist require more than a piece of paper and a dream.  So, I bought a book called something like “Learning to Draw in 30 Days.”  I am under no delusion that I am one month away from being a world-renowned artist, but I do think that by learning some lessons on shading, proportions, and perspective, I can be a better artist than I currently am.

Like so many people, though, the commitment to thirty days seems daunting.  I have, for the past month, constructed a number of reasons why I could not start the journey.  I am visiting my parents, we have a birthday party to prepare for, I am writing essays three times a week, etc.  I imagine that I am not alone in this.  Rather than starting, even if it means pausing the thirty days as events intervene, I make the perfect the enemy of the good.  I delay the beginning because I cannot conceive of the ending.  I call this emotional state “pre-exhaustion.”  It is when the process seems so daunting that I am too overwhelmed to even start. 

While my life on the spectrum may not help me in this case, I think that this sentiment drives how a lot of people approach process change.  Even if a process only requires finite time, many of us cannot help but focus on the end-state and crash-out on the seeming impossibility of getting there.  We become experts in “same management” which is the way we defer efforts at change management.

• Dramatize the costs.  When the lab director bemoaned “only two minutes a patient,” his staff could either point out that it takes longer than two minutes to do what he asked, or, that two minutes added 80 minutes onto their day.  In actuality, they did both by complaining that he added 80 minutes, when in reality it would be even longer than that. 
• Discount the benefit.  It can be easy to say that there will not be the level of improvement commensurate with the costs of implementation.  By dedicating 30-minutes a day to drawing exercises, how much better can I really get in a month?  If I focus on sitting down when I talk to patients, how much better will our scores really be?
• Catastrophize the process.  I have written before about what I have called the ‘N^th case’ where people don’t act because they are afraid of some random undesired outcome.  Beyond this, there can be a more pervasive fear that someone will make something worse by acting on the process.  So, a lab technician is afraid to say that they are drawing blood for a PSA test, because the patient is going to be panicked that the doctor thinks they have cancer, or will launch into an extended story about the time that their insurance didn’t pay for a specific test, so they got stuck with a surprise out-of-pocket bill.  If the phlebotomist had just said nothing, they would have been spared the anxiety or anger of a patient. 

At this point, it becomes easy to just avoid the process change.  Most of us have heard, or even used, the “I will start tomorrow” excuse, citing that they forgot or that today’s situation is not ideal.  We overestimate the costs in time and underestimate the value, so we adopt the “ask me tomorrow, when I have time” response.

All of these rationalizations are based upon a kernel of truth.  In the short term it is easier/faster/more efficient to not do something than to do it.   But by deferring the work, you defer the joy.  Every day that I don’t start drawing is a day further away from realizing my desire.  Every day that we wait for perfect conditions is a day when opportunities are lost.  I was never a big Pink Floyd fan in my youth, but as I get older, the lyrics of their song Time resonate.

¹I remember when I taught an introductory statistics class for social science majors.  While I rarely (but not never) hand-calculate a chi-square or t-test in the real world, I still think it is important for students to understand how the math works so they understand why a test is appropriate in a certain situation as well as know what makes a result significant.  I always had to pre-work the math step-by-step so that I could explain the how and why while writing it out on the board.  If tried to run on two tracks simultaneously, I would introduce stupid errors into simple math or pause and lose my train of thought. 

²OK, technically only 80 minutes.  Please forgive my egregious hyperbole. 

³This is a fact that anyone tasked with getting a patient to take a survey is keenly aware of.