A common theme in many of my essays is that the reason why many PX initiatives fail is because we do not address the underlying issues. Worse, we assume that the underlying issues are fine. Worst, we assume that the underlying issues aren’t important because healthcare is just different. So, we proceed, assuming that people want to be good communicators or embrace the mission. Or, more importantly, that pursuit of good communication or the mission will lead people in the same direction. And most importantly, that these things will just organically create a solid team. One of the biggest assumptions we make is that people understand that healthcare is a team sport. Sure, they may SAY they get it, but they don’t necessarily ACT like they understand this.
This is not an insult or evidence of a personal failure. Healthcare education trains doctors, nurses, technicians, that they need to take personal accountability for their actions. Even as they need to understand their position in the pecking order, they are inculcated with understanding that this is important work and their lapse can cost lives. That personal responsibility trumps all the other messaging. Even on a care team, if something goes sideways there will be someONE to blame. To be clear, this doesn’t mean all act with honor. I have served on too many root cause analysis sessions (where we discuss why some negative outcome occurred) and have seen too much scapegoating and blame-shifting to think people will always willingly fall on their sword. I would argue, though, that this actually makes my point. People point fingers because they know someone needs to be singled out. The team is not punished; the player is.
This essay, then, is not about blaming. This essay seeks simply to explore the tacit messages organizations send out that encourage people to focus on their personal accountability and not on organizational accountability. Without a broader view, patient experience suffers because assumptions are made and people can fall through the cracks. Too often this is a feature of the healthcare system and not a defect.
Patients see One Experience, Not Many Experiences
In all the conversations I have had with nursing unit managers, there is one topic that comes up in a vast majority of the time. They will complain that their PX scores get dinged because of the patient’s experience in the last care space. For example, many hospitals will not discharge patients from an intensive care unit (ICU) but instead transfer them to a step-down unit in preparation for their discharge. The nurse-to-patient ratios are different, and the care is not as omnipresent as it is in ICU. As you read this, I am sure you are thinking, “Yeah, that makes sense. Leaving ICU may mean that the worst is behind the patient, but they are not completely out of the woods.” The concern expressed by the step-down manager is that patients will see that the care is less intrusive and therefore think that the care is not as good. Similar logic is expressed by many inpatient nurses when they discuss the care differences between the emergency department and their inpatient floor.
The implication is that patients see their care as worse in this new space than it was in the previous space.1 But when I ask the leader if the care is actually worse in their space as compared to some other space, they will say that it obviously is not. But how would the patient know that? The problem is NOT that the care is better or worse, but that it looks different from what they had before and that no one prepared the patient for this difference in appearance. Those in healthcare see their piece of the process as separate and self-contained. After all, the care in each of these settings is different with different experts and different timelines. More importantly, it is performed by different staff that a single manager cannot manage.
Meanwhile, this is not how a patient sees things. A patient sees the act of calling their primary care doctor only to be advised that the patient should go immediately to the emergency room, where they are admitted, perhaps turfed to different units, and discharged, often with various lab and imaging interactions sprinkled throughout, as a single healthcare experience. They don’t see the various doctors and nurses flowing through their room as discrete events, but part of a larger whole. Expecting patients to parse this all out without any guidance from staff seems silly. If you are not preparing a patient for the change in care as they leave your care space or welcoming them to your care space by setting expectations, then don’t be surprised if they don’t see a unified team providing them care.
Self-Preservation
Like the previous one, this one is not exclusive to healthcare.2 I will leave it to others to speculate if the desire to avoid blame is a universal or learned human trait. In healthcare, part of the challenge is the fear of legal ramifications so there is some reticence to own blame that is baked into the process. But I feel like the desire to say, “Don’t blame me; blame that guy!” is more primal than legal. It is a rare person, who can stay calm in the face of vitriol and accept the message. To realize that while they, personally, may not be responsible for the gap in service, they also realize that they are a representative of the organization and face that storm without getting defensive. Now, as mentioned above, healthcare itself rewards this behavior, as they try to root out the reason why a bad thing happened. The morbidity and mortality (M&M) meeting’s primary goal is to figure out who fucked up and what the punishment should be for that error. So, we shouldn’t be surprised when the desire to cover one’s own buttocks is front and center and the team-concept floats out of the room when the angry patient speaks.
Bunker Mentality
In the last essay, I mentioned a unit manager who felt that it was their primary job to protect her team. So, she would push-back on any request of her team, whether it was a transfer from another hospital or another unit in her hospital or a new Human Resources directive or a change to documentation brought up by Clinical Informatics. While this person may be out on the right-tail of the bell curve, this behavior is common in healthcare. You don’t have to look around your organization too hard to find leaders or staff who stand at the parapet ready to howl bloody murder, should someone violate any rule, spoken or unspoken. Oddly, it doesn’t matter if the transgression is trying to give a team more work, or, trying to take work away from a team.
Clear-eyed honesty requires that I cite patient experience teams as a guilty party in this. PX teams often cry foul when some other department coopts PX training because “they don’t do it right.” They will complain when they do not have a seat at the table to hammer out some change in policy or design, since all things are “patient-facing.” At the same time, they may complain that so much of the patient advocacy or the day-to-day PX refresher and reminder work falls in their laps, instead with the department managers’ and directors’ laps. While there is a grain of truth in both of these concerns, honest self-reflection is needed to separate real workflow concerns with simple picking-and-choosing the fun stuff over the less-glamorous grunt work.
We are all being asked to do more with less and are being held especially accountable in these austere times. So, it is not surprising that this has created an environment where staff are patrolling their perimeter looking for offense by ignorance or design. The organization must accept that this, at least in part, is based upon a running calculus about their department’s efficiency and staffing scores. Sometimes patients become collateral damage in this battle.
We Focus on Differences, Not Similarities
One key reason why people focus on their team to the exclusion of other teams or departments is captured in the sentiment, “you wouldn’t understand what we really do.” I understand the motivation behind this statement even as it frustrates me. When I taught political science, I would explain that any significant piece of meaningful legislation required inclusivity rather than exclusivity. One would never get 100% alignment on an issue, but one still needed a majority to make something happen. Civil rights legislation required the support of white people. Women’s suffrage required the support of men. Social Security required support of younger people as well as older people who would not qualify. Poverty policies require the support of those who won’t qualify for them. Farm subsidies require the support of urbanites. Essentially, how do Democrats and Republicans win? By appealing to Independents and other fence-sitters. To win support, you need to be understood by those who don’t live your experience first-hand but are willing to bring empathy to understand your worldview in their own way. The ironic twist is that you need to understand where they are coming from if you want them to understand where you are coming from.3
The same is true in patient experience. I have had a few doctors tell me that, because I wasn’t a doctor, I could not teach them about patient experience because I didn’t understand their struggle. I would often respond that I probably didn’t, but I had a pretty good idea of the struggle their patients went through dealing with them. Indeed, it is not unusual to have clinicians and administrators gatekeep their space with the phrase, “you just wouldn’t understand.” There are, though, two outcomes from this worldview. The first is that you must allow the other person to gatekeep you. I get to say, “Yes, I understand as much about pediatric endocrinology as YOU understand about patient experience.”4 Chances are, any limitation you place on me will also limit you. The second, and more important, outcome is that you won’t stop the conversation, you will simply remove yourself from the conversation. I won’t stop constructing a PX vision, I will simply construct one without your input. You preventing my understanding does not prevent my oversight. The reality is that we are surrounded by people who don’t truly understand our first-hand experience. By denying their agency, we are simply giving them a reason and the power to ignore us.
By not stressing the importance of a team mindset, not only are we missing opportunities to improve employee job satisfaction and patient experience, but we are also missing opportunities to improve flow and reduce errors through collaboration. Our own organizations can exacerbate this problem by ignoring it or even playing into it. In the next essay, I will discuss ways that organizations can change their approach to patient experience as a way to dismantle the silos and build a true team identity.
1This is not completely true, since often inpatient staff will criticize the ED staff for setting expectations so low, but that is a subject for another essay.
2As a frequent traveler, I know that housekeeping, food service, facilities management, concierge, and front desk staff are all different departments, but I get frustrated when someone will tell me it is “not my department.” Yes, I called the front desk for more coffee packets and I know they won’t bring them to me, but I expect that they can route my request rather than giving me a different telephone extension to call.
3As a sidenote, if you are reading this and thinking, “Yes, those guys on the other side of the political spectrum are the worst!” then you are likely not realizing how often you do the exact same thing. Identity politics has the same impact, regardless of whether it is based upon the color of your skin or the color of your baseball cap.
4I am reminded of a situation where I was working with a physician on some PX work. We had been at it for quite a while and in one meeting, “Well, Bill, I think we should…” He winced and stopped me, saying, “I would prefer you call me Dr. Cotton.” I said, “I am sorry; Dr. Cotton, I think we should…” Later in the same meeting, he said, “Joe, it would be helpful if…” and I stopped him. I said, “I would prefer it if you called me Mr. Snipp.”
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