A couple of weeks ago, when I organized my essays, I realized that I was about to write my 100th essay.1 I wondered if it was worth calling out in some significant way, since it seems like an accomplishment, but I could not think of a topic that would warrant the klieg lights of that distinction. When I woke up last night at about 2am, because Ellie was requesting a bathroom break, my sleep-brain suggested that I do a “clip show” for this milestone. That is a bad idea (sleep-brain), but I then realized that I have a lot of content that has been cut from past essays and it might be interesting to give that writing some attention. If this website is my discography, then this essay would be a collection of demo tracks, B-sides, and live versions. Maybe not cohesive or, um, good, but perhaps of interest to fans or completists.
It might help to give some background on my writing process. I usually start with a concept that I want to write about. Even if I am not 100% sure what I am going to say, or whether there is even enough material there for me to write a full essay on, I just set out. I am guided by the voice of my Risk/Quality folks in my head, telling me to “trust the process.” Since sometimes the ideas come faster than I can type, I will often have a running list of points or examples that act like a de facto outline. When I am finished, I will walk away from the writing for a couple of hours and then return and edit. At that point, I will add exposition on stuff that I think needs more clarification or context. I will also cut stuff, like elements from the running outline that didn’t make the final edit, or material that did not further or develop the essay’s thesis. Some of that stuff gets lost to the ether, but some gets put in a word document2 called “cut stuff” and may eventually be reworked into a different essay. But for the stuff that I think is interesting, but not germane to the topic and not expansive enough to be its own essay, it just lays there waiting. So, today I sifted through the dross, looking for things that are interesting, if not worthy of top billing. If they don’t end up being interesting, well, that will explain why they were cut in the first place.
If at first, you don’t succeed…
Anyone’s first effort rarely is brilliant or 100% successful. But for there to be a second effort, the first effort has to exist. My research company had a yearly conference where they gave out awards to hospitals, clinics, and physicians who performed exceptionally well. In accepting an award, a physician challenged other physicians that when it came to patient experience, “you are not failing enough.” He meant that if they were not failing, it was because they were not pushing themselves, not trying new things, and not moving out of their comfort zone. So, if you aren’t failing, it means you are not trying to improve.
I often use a version of this when I am spearheading a team. I will say, “Let’s make new mistakes.” When people look at me quizzically, I say, “Anyone can make the same old mistakes again and again. If we want to get better, we need to make new mistakes and learn from them.” My message is designed to relieve the stress of thinking we need to be perfect as we set out in a new way. What we have isn’t perfect, so we don’t need to replace it with perfection. We need to replace it with an effort to become more perfect.
If you don’t understand history…
You cannot change the status quo without understanding it. There seems to be this belief that we did things the way we did because we were stupid or insensitive. This may make you feel superior or more enlightened, but it will also likely set you up for failure. The reason we created the intake form we use, or organized the storage closet the way we did, or did ANYTHING in the past was to satisfy an issue. Sometimes the world changes. We move from paper forms to electronic forms. Perhaps the supply chain process changes. Sometimes the world doesn’t change and why we do things is driven by less obvious and unchanged reasons. By not examining these things, we may create a process that will not improve flow and flexibility. It might even make it worse.
So, there are times when we need to modify behavior and there are times when we need to modify the process. Sometimes this depends more on a person’s desire to control than it does on a desire to create workable solutions. I remember being in a college class and the professor was complaining about how students were cutting across the lawn instead of taking the sidewalk to get into the building and it was killing the grass. “Why can’t you just take the sidewalk?” I raised my hand and asked, “Why can’t we just redesign the sidewalk to match traffic patterns?” I am not saying I was right and the professor was wrong. I am saying that one needs to understand the behavior to determine if you can modify it, or remove the need to modify it.
There are certainly times in patient experience when modifying behavior is the right decision. There are also times when the reality of life will not allow behavior to be modified. So, you can tell a provider to sit down when they enter a room, but before you chastise them for not doing so, first look around and see if there are chairs. Being successful in PX action planning in large part is operationalizing the serenity prayer, which asks for the serenity to accept what cannot be changed, the courage to address what can be changed, and the wisdom to know the difference.
The donut and not the…
A few years ago, I had what I call my ‘spa day’ when I went to the emergency room, got admitted and spent the night. You have probably surmised from reading these essays that I have an affinity for coffee and the naturally-occurring stimulant that it contains. After going about 30-hours without a cup, I had a bit of a caffeine headache. When the certified nurse assistant (CNA) asked for my pain level, I reported that it had gone from a 0 to a 2. She started to stammer about how I was having a procedure today and that she might not be able to get me pain medicine, but she could check with the doctor, and… I stopped her and said, “how about an ice pack?” She said that she certainly could get me that and problem was solved. She was so focused on what she could NOT do that she didn’t consider the things she could do. It is not uncommon for us all to suffer from target blindness. This is when we become so fixated on a specific problem and solution that we often overlook options and fail to identify the target even when we are looking directly at it.
I have been called an ‘absent-minded professor’ because of my (alleged) intellect combined with my (alleged) inability to find things that are (allegedly) right in front of me. What I have found as I reflect on this, is that I make a lot of assumptions when I am looking for something. In an effort to cull the abundance of information, I narrow my search parameters. This is useful but can lead me astray. For example, I went into the cupboard to find some paprika. Since 99.977% of all spices come in a small cylinder of plastic or glass, I immediately discount the big boxes and the wide-mouthed jars and focus on the smaller containers. But I cannot find it and later discover this is because Katie bought a large metal tin of imported Hungarian paprika, which did not conform to the search parameters. Now you can make fun of me (or men, or blondes, or whatever stereotype you embrace), but if you want to problem-solve, it is far better to reflect on why people are not being successful and adjusting your action-plan than just shaming people for failing.
Means to an end…
I get irritated when I hear healthcare people complain, “but we are a hospital, not a hotel!” though not for the usual reasons. Yes, as I have said before, it misunderstands the concept of patient experience. If you think PX is “a mint on the pillow” than you don’t understand what the patient experience team is trying to get you to do.
I get irritated because this misunderstands what a hotel is all about. Hospitals and hotels are similar because they are BOTH means to an end. People don’t want to go to a hospital; they NEED to go to a hospital. Likewise, people don’t want to go to a hotel; they NEED to go to a hotel. Now hold on, my hospitality folks, who I know read these essays. Give me a minute before you flame me in the comments. People book a hotel because they want to go on vacation or they need to take a work-trip.3 Some may book a hotel in their own home-town because they just want some peace and freaking quiet. The hotel room is a means to an end. Ideally, it is still a comfortable, well-appointed means to an end with shuttle service to the airport or points of interest. A good hotel room gives thought in the design to how it will be used (see my essays on the two hotel rooms I stayed in on a trip to Vegas). So, the TV faces the bed; the chair faces the window; the towels are in the bathroom; the coffee maker is by an outlet. It is not outrageous, then, to expect a hospital dedicate the same attention to how their rooms are laid out. Saying that a hospital is not a hotel seems like an excuse to not consider comfort and functionality in a hospital, which seems doubly-offensive, given the anxiety of the average patient.
That’s just who they are…
Since we are discussing things that annoy me, I also get frustrated with the notion that PX is all about being robotic or fake or plastic. Clinicians will complain about scripting or behavioral expectations as the administration trying to create Stepford Doctors and Nurses, all moving in lockstep and parroting the same phrases. I cannot speak for others, but that is certainly NOT my intention.
This often carries an implicit (sometimes explicit) statement that being nice is not in their job description. I completely disagree with this, though. A clinician’s job is to build connections and confidence in people. Their job is to inspire patients to follow instructions and coworkers to be thoughtful and attentive to detail. Their job is to be nice to people. By treating conduct as simply an add-on, or a side-benefit misses the essential point of the work we do. Asking people not to be rude, especially to those who cannot fight back, is not an outrageous request. This is not about being exactly the same. It is about not being a jerk.
I am reminded of something my father said to me one day after school. I was struggling with calculus and said that the teacher was really smart, but it all was going over my head. My father said that if this was the case, then the teacher wasn’t really very smart. Smart people, especially smart teachers, should be able to explain something in a way that the student can understand. It is the core of the job description. To be clear, my parents were both teachers and my father was not suggesting that I shouldn’t work hard at learning. I had to do my part. But a conversation between teacher and student is like a conversation between a clinician and a patient. It is not a conversation between equals. And when the superior one chooses to punch-down versus raise-up, it is not a choice, but a personality flaw.
OK, that was fun. I barely scratched the surface of deleted content, so perhaps I will do this again sometime. For those who have been reading since the beginning, thank you. For those who have joined the journey along the way, thank you as well. And now on to another 100…
1By the way, I do NOT appreciate the shade, Microsoft Word. It auto-filled “birthday” after I typed 100th. Very hurtful.
2Actually, I just counted and I have 14 such Word documents. So, for those who think my essays are too long, just know that they could be a lot longer…
3Even for ‘destination hotels’ attached to renown spas, golf courses, or amusement parks, the room is just a comfortable place to be between expert massage therapy, rounds of golf, or photos with loveable cartoon characters.
PX Matters with Joseph Snipp 
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