When I taught political science, I stressed that to understand those sitting opposite you on the ideological spectrum, you needed to understand the context of their ideology. Without an appreciation of their logical structure, it became too easy to tar the opposing side as simply lacking some important value that you possessed. An example would be people who self-identify as “pro-choice” or “pro-life” and thereby define their opposition as “anti-choice” or “anti-life.” When we describe our opponents as not possessing some character trait that we find important, at best we can dismiss them and at worst, we can demonize them. This dehumanizes them and they become easier to pigeonhole them and their concerns or needs. This isn’t reserved for political discussions.1 Ask a salesperson their opinion of the average customer. Ask a college professor their opinion of the average freshman. In my universe, ask an emergency department doctor their opinion of the average ED patient. In each situation, the nuance and the needs are discarded and the person before them is simply an amalgam of all their worst traits. When we focus strategies exclusively on fixing the assumed problems of these people, we perpetuate the vicious cycle. We seek to fix problems, which means we only see problems, which means that we define our audience as essentially problematic.
In the last essay, I explored why focusing exclusively on problems was dedicating resources to the wrong target. In this essay, I will examine what this focus brings to our approach to improvement strategies. The thread that you will see woven through all of these points is that if all we see are problems, then everyone around us is seen as simply an obstacle to our success.
Problems are a Blunt Knife
Most of the mistakes we make in PX are not things we do wrong, so much as they are things that we overemphasize or overanalyze. For example, I DO think it is important to read the comments patients leave on surveys, post online, or communicate in letters. It is the one place where people are given full freedom to discuss what they think is important and not just rate us on the things WE think are important. Having said that, we often don’t review them through the right lens. I think I wrote an entire essay on how to process patient comments, so I won’t rehash old territory.2 Here, I will focus on one key element. We mistake what people complain about for what they care about.
The reality is that when people complain about something, it is often because they are triggered to think about bad things specifically. The first question anyone wants to add to a survey is, “What could we have done better?” The question is asking what problems they had, so they will mention something, regardless of whether it is really all that important. This sends staff and clinicians down a rabbit-hole as they obsess about the criticism, regardless of who the person is or how they lodged the complaint.
Too often we pore over survey responses which require the least amount of effort. A patient answered the phone or opened an email and started to take the survey. These require the least amount of activation energy. They may have answered the question, having given it very little thought. Meanwhile, when a patient writes a letter outlining their experience, we often relegate those to either the patient advocate for service recovery or share them broadly with staff as an atta-boy/atta-girl. These were thoughtful expositions that required a lot of work, including figuring out where to send the letter. These rarely get reviewed as a source of patient experience work. Ironically, they will get dismissed as “one person’s account” while that same one person’s comment on the survey is examined more thoroughly than the Zapruder film.
Problems are Seen as Simplistic
As we focus on the problems and this focus reframes how we view our patients, we can often misunderstand what our patients are really trying to tell us. We often assume the lowest common denominator. For example, I have had outpatient clinics complain about the feedback that they get from patients. I have had clinic managers complain to me about some of the comments they get. Patients will complain about the quality and expiration date on the magazines,3 or the volume and/or channel of the TV, or the comfort of the chairs. The manager will either say:
- I can’t do anything about these things
- I am not running a library or salon, I have more important things to focus on
The problem is that by minimizing the complaint, calling it superfluous or silly, you are saying something about your patients. You are saying that your patients are too stupid to evaluate the “important” things in the clinic, so they are focused on the superficial things.
When confronted with a comment about the comfort of the waiting room, I once had a manager say, “I am not running a waiting room!” to which I said, “Yes, you are.” She was running a clinic, yes, but the waiting room was part of that clinic. She was not focused on the right thing. She was misunderstanding what the patients were saying. I pointed out that there is one patient who will NEVER complain about anything in the waiting room. These are the patients who don’t spend any time in the waiting room. Most complaints about waiting rooms are not about the fixtures and furniture, but about the fact that they were in the waiting room long enough to form an opinion on the fixtures and the furniture.
Notice how reframing this comment changes completely the focus of the patient. They are not snobs passing a jaundiced eye at the meager offerings of this waiting room. They are annoyed that they are sitting in the waiting room and not back with their doctor. They are frustrated at the fact that this delay is going to set back their whole day and TV shows on home-makeovers isn’t going to change that. They are anxious about whether they will be taken seriously by their doctor or whether they are sick or they are SICK. If you accept patient complaints superficially, you will likely define your patients as being superficial. If you define their problems as “out of my control,” you are giving yourself an excuse as to why you are not addressing your patients as people. Speaking personally, as a customer, nothing makes me want to scream more than a salesperson, waiter, gate agent, hotel desk agent, etc. say “that is out of my control” as if I shouldn’t get irritated or I don’t have a legitimate concern. Likewise, asking a patient to tell us what we could do better and then dismissing what they say as out of your control is insulting. You might as well change the wording of the question to:
What could we have done better, but please limit your comments to things that are actually within our ability to control or affect. Please refer to the associated list of topics that are in-scope and out-of-scope for this question. All answers the disregard this list will be ignored.
Focusing on the Wrong Patient
OK, some will think that what I am about to say is blasphemy. I don’t think all negative comments are the same. I think we should prioritize them. Now before you pillorize me, I will stress that this comment is in regard to improving the patient experience. If any patient makes a complaint of a serious complaint about a gap in care, we should take that seriously and follow up with that patient. But when we are talking about service excellence or service improvement, I am focused on our primary target. You can debate me in the comments below, but the only patient comments I care about from a service improvement standpoint are those made by people who gave me a “7” or an “8.” These are folks who were just outside our desired score and their suggestions could be what moves them into the golden zone.
Meanwhile, the other two groups—the 9s/10s and the 0s-thru-6s—mean nothing to me. I definitely care what the 9s and 10s think about what we did well, since that might be what got us that score. But anything they suggest we could do better exists in the universe of a distinction without a difference. We didn’t do what they suggested, and they still gave us the desired score. On the other end, someone giving us a truly bad score likely has significant issues with our service. Their comments may or may not be useful from a service recovery viewpoint, but they aren’t giving us a path to improvement. We may need to address their concerns to metaphorically stop the bleeding, but they are not likely to give us broad direction on tipping the scales, as in how to move them from “hate” to “love.” In a space of limited oxygen, making the happy even happier and the miserable slightly less miserable is secondary to focusing on the things that could make a real difference. If it makes you more comfortable, you can define these patient suggestions “nice-to-have” suggestions, while those made by the 7s and 8s more as “must-have” suggestions.
Focusing on the Wrong Direction
If you focus on comments, you have a tendency to be looking in the wrong direction for help. That comment that you are reading was made by a patient who experienced your care last week, and upon reflection, told you what you could do better. But people often forget that there is NOTHING they can do to change the score that this patient gave you. They are gone. They are out of your sphere of influence. That score is locked in and logged as a win or a loss. By focusing on those comments (especially in conjunction with taking them literally), we are trying to fix prospective care with retroactive solutions. Or, to put more simply, we are trying to drive to work, only looking in our rearview mirror.
This takes the concept from the last essay about how fixing problems is retail and pushes it further by highlighting that it is particular as well. The key with reading comments is to glean lessons from them that can be used to inform the next patient. This is the patient we CAN influence. The key is not to give them the solution that the last one asked for but instead look at the underlying concern that the last patient gave and tailor a response that will engage the next patient, indeed all of the next patients.
In looking at all of these issues, consider how these things affect how we view patients. We see these people as either problems that we need to solve, or problems we roll our eyes at. Both of these define patients as obstacles to our work. Even the problems we think are significant often get buried under layers of “not my job” or he-said/she-said debates about whether the provider was “rude” or “dismissive” and never really get addressed or fixed. Nothing shows more about the dehumanization of our patients than that.
1When people find out that I taught political science, they will say, “I bet you love this time of year.” But I look at the election year in late-October much like I look at winter in late-January: I enjoyed its charms, but I am ready for it to be over.
2I say “think” because with well over 100 essays and about 20 others in some form of construction, I cannot remember off the top of my head if I actually published it and don’t want to take the time to look. Obviously, if I didn’t, or you want more on that topic, feel free to mention it in the comments.
3I should quickly point out that our Infection Preventionists have removed all magazines out of all waiting rooms, post-COVID.
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