A million years ago, I heard a dentist describe their work as, “tooth decay is a terrible thing, but where would we be without it?” Now clearly dentists do things other than fill cavities, but I thought that this was a telling self-definition that explains a lot of what we get wrong when we talk about patient experience and healthcare. We often focus on fixing the problem we are confronted with rather than putting this problem within a broader context of care and addressing that. Before you jump on me, healthcare IS focused on addressing underlying issues and not just symptoms that pop up. We want to address the underlying diabetes and not just the resulting neuropathy. We want to address the suboptimal life choices—like smoking or diet or alcohol consumption—rather than just the problems they create. But just as I will admit this, I will also call out that we spend far more blood and treasure fixing existing problems rather than on steering people towards behaviors that will minimize future problems. This is not some new-age rant about how healthcare’s profit-motive is to keep you sick. This is, though, a rant on how observing the world through this lens of spotting and fixing problems does not make the patient experience any better.
Like most things, this focus starts in a reasonable, even laudable, place. Fixing problems is not a bad thing. It almost goes without saying that we need to replace soiled ceiling tiles, mop up spilled liquid, sweep up broken glass, and repair or replace broken furniture. But when that is all that we focus on, it is all that we see. We become very task-oriented and that eats up all of our time. And while that is important, we often don’t reflect upon what we could be doing if we realized that our time is a finite resource and that all the time we spend fixing problems is time we are not spending on improvement. When we got out of school and entered the labor force, did we aspire to be doing “busywork,” “grunt work,” “housekeeping,”1 or “level-setting”? While fixing problems is important, by limiting our focus, we miss out on things that are equally, if not more, important.
When it comes specifically to patient satisfaction, this focus on problems misses the point of the work. When you look at your hospital’s patient experience data, you will see that somewhere between 75% and 95% of your patients2 are broadly satisfied. That is, they are giving you a 9 or 10 or a 7 or 8. They are giving you an “always” or a “usually.” They are giving you an “excellent” or a “very good.” There are very few people down in the 1 or 0 categories, just as there are few people giving you a “never” or a “poor.” So, while fixing problems is important work, it does not address where a vast majority of your patients are. You will not improve your scores by simply addressing problems. In fact, spending a lot of time resolving problems will likely get you further from where you want to be. Here are a few reasons why.
Fixing Problems is Ad Hoc and Specific
Addressing issues as they pop up is like playing whack-a-mole. When a call, email, or ticket comes in saying that there is an overflowing toilet, burned-out light, or broken TV, we can run out and address it. And we need to. But we also need to realize that this specific issue in this specific space has not addressed any broad concerns. In PX, we see this especially when a patient logs a complaint/grievance or makes a negative comment on a survey or in a review. We need to address these things and make things right. But we cannot deceive ourselves that we are making a broad contribution to our patients’ perceptions. I call this retail PX. We are tailoring a response to one patient’s specific concern. Important? Yes, but very particular. For PX to be successful, we need a more wholesale approach, where one behavior can connect with multiple patients. One well-structured initiative will touch far more people than writing letters to 100 irate patients.
Imagine there is one patient on a unit who has a legitimate concern about something. We send the nurse, the nurse manager, the patient advocate, other leaders, even a senior leader into that room to address that concern. After all that effort, we may have moved that patient from dissatisfied to somewhat satisfied. Or perhaps vocally-dissatisfied to quietly-dissatisfied or maybe even begrudgingly-satisfied. Job well done! But what effect has this had on the other patients on the unit? Nothing that was done for that one patient will impact how the other patients rate their experience. In fact, I would argue that their scores might be slightly lower for all that work. After all, the effort by all those individuals directed at that one patient means marginally less time and effort dedicated to the other patients on the unit.
It Defines the Work
It is true that fixing problems can have some small collateral impact. Replacing a broken TV not only improves the complaining patient’s experience but proactively improves all new patients who are admitted to that room. Assuming that they turn on the TV. When I have rounding on patients, most of the time they don’t have the TV on. This doesn’t mean that they never turn on the TV. But it does raise the question of how important that TV is to their experience. Since we can agree that hospital budgets are tight, chasing new TVs or more expansive cable packages needs to be balanced against, say, a more robust Wi-Fi that can handle more traffic and even support streaming.
There is an assumption that if one person makes a complaint, that this complaint is just the tip of the iceberg. So, if we address this complaint, we are proactively addressing a lot of unspoken concerns. While like with many things, there is a grain of truth here, this does not count as improving the patients’ experiences. First of all, just because similar complaints are logged, doesn’t mean that they are the same, or can be fixed in the same way. The primary complaint that I have heard when talking to patients about their TVs is the array of channels available on the hospital television. The obvious fix, then, is to expand the offerings. But if you ask one more question “what would you like to have available?” the solution falls apart. Because while many people might say that they want more options, what they are really saying is that they want more sports channels, or Hallmark channels, or news channels that conform to their personal political persuasion. I remember rounding on a patient in Richmond, Virginia who was upset that he could not get a pay-per-view fight on his TV. He said that he was even willing to pay for it but was annoyed that it was not even available. Even if you wanted, then, to expand options, there would be no consensus as to what expansion would satisfy the patients.
The lack of clear direction then brings us to the second issue here. The organization’s inertia to fix the problem, or, the organization’s perspective on what the fix should be, or, even an organization’s desire to fix a problem which is not the patients’ concern. For example, scheduling is a struggle for most hospital systems. Patients will complain that they have to make multiple calls or get transferred multiple times in order to schedule an appointment. A complex process that used to be as simple as calling Denise at the clinic because she knows me and knows what appointments will work for me.
But hospitals complain that scheduling costs a lot of money. There are variations in physician preference for appointment times and workdays. There are the patients entering the scheduling system not fully aware of what they need or what might be covered by their insurance plans or what might need a preauthorization. Then there is the eternal balance of having enough staff to manage the calls and keep doctor schedules full, but not too many staff members that lead to wasted manhours.
I remember going to a hospital system with survey data saying, “Patients hate the scheduling process!” There was a lot of data to indicate that feelings on scheduling were dragging down scores. The response I got was, “We are fixing it!” The scheduling team was standardizing appointment times and creating phone trees so, after a few simple questions to a patient, they could be routed to the right human. Needless to say, when patients complained, they were not saying that the current system was insufficiently impersonal or expensive. They were not complaining about the fact that they didn’t get transferred or left on hold enough. By focusing on complaints to drive PX, we are pre-defining what will make people happy while at the same time, we are often supplanting our perspective for theirs.
Focusing on the Hole and not the Donut
This is one of my favorite stories to tell when I present. I ask where the golfers are and I ask them to imagine this:
You are standing on the 18th hole, having a very good day, where you are playing really well. Not perfect, but one of the better rounds you have played this year. You look at this hole, a Par 4 with a dogleg left around a water hazard and you think, “hey, if I play this right, I can get to the green in two strokes, and maybe I can finish this round with a birdie, if not a par. All I gotta do is not put it in the water. Don’t put it in the water. Avoid the water…”
And I ask the group, “And where does the ball go?” People shout back, “Right in the water!” Even people who don’t golf can understand that feeling. Why is it that we spend so much time focusing on the outcome we don’t want, only to end up getting that outcome? I think it is because it was the only outcome we specified. We did not say what a GOOD outcome was, only what a BAD outcome was. We didn’t say, “So let’s aim for that fat part of the fairway.” Marketing types will say that effective ads don’t talk about negative behaviors or images, but positive behaviors or images. Psychologists point out that obsessing on negative behaviors just leads to more negative behaviors. If we want to pursue positive outcomes, we need to focus on positive outcomes. PX is the same way. If we focus exclusively on gaps or problems that patients express, we will quickly miss that what most patients want is not fewer broken TVs, but more communication and teamwork.
After reading this, some of you may accuse me of embracing the law of attraction, the pseudoscientific belief that drives most vision boards. That is not my point. I am by no means saying that simply staying positive manifests positivity. What I am saying is that if you define the world simply as an array of problems, you are missing a lot of opportunities to improve the overall situation. While fixing problems is necessary at times, it also doesn’t get us closer to improving the overall experience, be that employee, customer, or patient. If we want to improve experiences, theirs or ours, we need to focus on the behaviors that are likely to lead to improved experiences. I will discuss what this looks like in the second essay.
1I mean no disrespect to people who work in housekeeping, which is hard work. I am using this is the corporate-speak of “the annoying little details we need to take care of before the real work can begin.”
2This obviously can vary by care space, where emergency department scores tend to be lower than inpatient scores and inpatient scores tend to be lower than outpatient clinic scores. Regardless, though, a majority to a vast majority of patients are happy with the care they receive.
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